From Madness to Mental Health

page ii is blank.
From
Madness
to
Mental Health
Psychiatric Disorder
and Its Treatment
in Western Civilization
Edited by Greg Eghigian

Rutgers University Press

New Brunswick, New Jersey, and London
Library of Congress Cataloging-in-Publication Data

From madness to mental health : psychiatric disorder and its treatment in Western
civilization / edited by Greg Eghigian.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-8135-4665-0 (hardcover : alk. paper) — ISBN 978-0-8135-4666-7
(pbk. : alk. paper)
1. Psychiatry—History. I. Eghigian, Greg, 1961–
[DNLM: 1. Psychiatry—history—Collected Works. 2. Medicine in Literature—
Collected Works. 3. Mental Disorders—history—Collected Works.
4. Mental Health Services—history—Collected Works. 5. Mentally Ill
Persons—history—Collected Works. 6. Western World—history—Collected
Works. WM 11.1 F931 2010]
RC438.F76 2010
616.89—dc22
2009008508
A British Cataloging-in-Publication record for this book is available
from the British Library.
This collection copyright © 2010 by Greg Eghigian
For copyrights to individual pieces please see last page of each essay.
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For the countless many
page vi is blank.
 Contents

List of Illustrations xi
Acknowledgments xiii

Introduction 1

Part I The Pneumatic Age 7

The Ancient World

The Bible, 1 Samuel (ca. 960 b.c.e.) 10
Euripides (484–407/6 b.c.e.),
The Bacchae (ca. 404 b.c.e.) 18
Hippocrates (460–377 b.c.e.),
Writings on Hysteria (ca. fourth century b.c.e.) 30
The Bible, Mark 5 (ca. 65–75 c.e.) 36
Soranus of Ephesus (ca. second century c.e.),
“Madness or Insanity (Greek Mania)” 39

Medieval and Early Modern Europe

Sara–biyu .
– n Ibn Ibra–hi–m, “Three Cases of Melancholia
by Rufus of Ephesus” (ca. 873 c.e.) 47
Ibn Si.
–na– [Avicenna] (ca. 980–1037),
“Lovesickness” (First Latin translation, twelfth century) 50
Julian of Norwich (1342–ca. 1416),
Revelations of Divine Love (ca. 1390s) 53
Desiderius Erasmus (ca. 1466 –1536),
The Praise of Folly (1511) 60
Robert Burton (1577–1640),
The Anatomy of Melancholy (1621) 67

vii
viii — Contents
John Brydall (ca. 1635–ca. after 1705), The Law Relating
to Natural Fools, Mad-Folks, and Lunatick Persons (1700) 73
Hermann Boerhaave (1668 –1738), “Aphorisms” (1765) 80
William Cullen (1710–1790),
Lectures on the Materia Medica (1773) 85

Part II The Age of Optimism 91

Enlightenment, Romanticism, and Reform

Philippe Pinel (1745–1826), A Treatise on Insanity (1801) 94
Johann Christian August Heinroth (1773–1843),
Textbook of Disturbances of Mental Life (1818) 105
Jean Etienne Esquirol (1772–1840), “Monomania” (1838) 111
Dorothea Dix (1802–1887),
Memorial to the Legislature of Massachusetts (1843) 116
The M’Naughten Rules (1843) 123

The Asylum
The Opal: A Monthly Periodical of the State Lunatic Asylum,
Devoted to Usefulness, Edited by the Patients of the Utica State
Lunatic Asylum (1850–1860) 134
Limerick District Lunatic Asylum, Report of the Limerick
District Lunatic Asylum for the Year Ending December 31st,
1866 (1867) 143
Office of Superintendent Government, Great Britain,
Annual Report of the Insane Asylums in Bengal for the Year
1867 (1868) 155
Elizabeth P. W. Packard (1816 –1897),
The Prisoners’ Hidden Life, or Insane Asylums Unveiled (1868) 162

Brain Science, Nerves, and Clinical Psychiatry

Nelson Sizer (1812–1897), Forty Years in Phrenology:
Embracing Recollections of History, Anecdote, and Experience
(1891) 168
George Miller Beard (1839–1883), Cases of Hysteria,
Neurasthenia, Spinal Irritation, or Allied Affections (1874) 175
Auguste Tamburini (1848–1919),
“A Theory of Hallucinations” (1881) 179
Richard von Krafft-Ebing (1840–1902),
Psychopathia Sexualis (1892) 184
 Contents — ix
Jean-Martin Charcot (1825–1893),
“A Tuesday Lesson: Hysteroepilepsy” (1888) 193
Emil Kraepelin (1856–1926), “About the Surveillance
Ward at the Heidelberg Clinic for Lunatics” (1895) 200
Sigmund Freud (1856 –1939), “The Origin
and Development of Psychoanalysis” (1910) 207
Vincent, “Confessions of an Agoraphobic Victim” (1919) 223

Part III The Militant Age 229

War and Neurosis

Fritz Kaufmann (1875–1941), “The Systematic Cure
of Complicated Psychogenic Motor Disorders Among
Soldiers in One Session” (1916) 233
W.H.R. Rivers (1864–1922),
“War Neurosis and Military Training” (1918) 238

The New Focus on the Body

Anonymous,
“Autopsychology of the Manic-Depressive” (1910) 245
Herman Lundborg (1868–1943),
“The Danger of Degeneracy” (1922) 252
The Decision in Buck v. Bell (1927) 256
Julius Wagner-Jauregg (1857–1940), “The Treatment
of Dementia Paralytica by Malaria Inoculation” (1927) 260
Hermann Simon (1867–1947),
Active Therapy in the Lunatic Facility (1929) 271
Anonymous, “Insulin and I” (1940) 275
Walter Freeman (1895–1972) and James W. Watts
(1904–1994), “Psychosurgery during 1936–1946” (1947) 283

Psychiatric Eugenics in Nazi Germany

Fritz Lenz (1887–1976),
Human Selection and Race Hygiene (1921) 294
Germany, “The Law for the Prevention
of Hereditarily Ill Offspring” (14 July 1933) 299
Documents on the “T-4” and “14f13”
Programs (1939–1945) 304
x — Contents
Mental Illness, Psychiatry, and Communism
Thea H. (b. 1923), An Experience of Psychosis
in Post–World War II Germany (1949) 312
Records in the Case of Pyotr Grigorenko (1969–1970) 317
World Psychiatric Association,
“Declaration of Hawaii” (1977) 329

Antipsychiatry, Social Psychiatry, and Deinstitutionalization

Frantz Fanon (1925–1961),
“The ‘North African Syndrome’ ” (1952) 333
Thomas Szasz (b. 1920),
“The Myth of Mental Illness” (1960) 346
Franco Basaglia (1924–1980),
“The Problem of the Incident” (1968) 352
Department of Health and Social Security, Great Britain,
Better Services for the Mentally Ill (1975) 357

Part IV The Psychoboom 369

Alcoholics Anonymous (founded 1935),

“The Twelve Steps” and “The Twelve Traditions” 373
Carl Rogers (1902–1987), “The Attitude and Orientation
of the Counselor in Client Centered Therapy” (1949) 376
Aaron T. Beck (b. 1921), “Cognitive Therapy:
Nature and Relation to Behavior Therapy” (1970) 382
Edna I. Rawlings and Dianne K. Carter,
“The Intractable Female Patient” (1977) 392
Diagnostic and Statistical Manual of Mental Disorders-III,
“Post-traumatic Stress Disorder” (1980) 401
Psychiatrists Debate Osheroff v. Chestnut Lodge (1990) 405

Appendix: Bibliography of First-Person Narratives of

Madness in English (Fourth Edition) by Gail A. Hornstein 421

Index 453
 Illustrations

A representation of the mythical Thracian king Lykurgos 19

Madness Is Deceptive (1669) 71
Laginet, Allegory: Women Have the Stones of Folly Removed
from Their Husbands’ Heads (eighteenth century) 79
Philippe Pinel has the irons removed from the insane at Bicêtre 95
Two views of circulating swings for treating insanity 103
William Hogarth, Scene in Bedlam (1735), from A Rake’s Progress
(plate 8) 135
Francisco José de Goya y Lucientes, Lunatic Asylum (ca. 1812–1819) 153
Interior view of a corridor in the asylum at Norristown,
Pennsylvania, United States (1896) 161
A model phrenological head (1887) 169
Andrea Brouillet, A Clinical Lesson with Charcot at the Salpêtrière
1887 195

xi
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 Acknowledgments

This project was inspired, first and foremost, by students, friends, and col-
leagues. For some ten years now, I have taught a course on the history of
madness and psychiatry in the Western world. Like many of my colleagues
who teach their own version of this course, I found myself wishing there
were an anthology of primary sources that could provide a glimpse into the
long and complex history of mental disorders and their treatment. Over the
past decade, historians, social scientists, and former patients have done a
remarkable job of rewriting the secondary history of madness and psychia-
try. And yet introducing students and other interested readers to the rich
fund of primary sources in this history has often been an unwieldy task.
After years in which I distributed photocopies and placed books on reserve
at the library, the time seemed right to compile a collection of texts from
well-known, little-known, and long-since-forgotten sources. I have no
doubt that the selections made—and not made—will invariably disap-
point. It is my hope, however, that in some small way this collection will
kindle insight, provoke discussion, and encourage further reading. The
intention is to provide a starting, not an end, point for thought and study.
I am indebted to numerous individuals and institutions for their help
and support. Both the College of the Liberal Arts and the Rock Ethics Insti-
tute at Penn State University provided needed financial support to see this
project through. I am also grateful for the generous assistance given to me
by the staff at the National Library of Medicine as well as the Staatsbiblio-
thek in Berlin. I received invaluable suggestions and criticism from numer-
ous colleagues and friends, in particular Jesse Ballenger, Viola Balz, John
Burnham, Michael Carhart, Kumkum Chatterjee, Eric Engstrom, Gerald
Grob, Baruch Halpern, Volker Hess, Andreas Killen, Ulrike Klöppel, Paul
Lerner, Benoit Majerus, Bill Petersen, Hans Pols, Sajay Samuel, Ulf
Schmidt, Michael Sokal, and Chloe Silverman. Doreen Valentine has been
xiii
xiv — Acknowledgments
an ideal editor, shepherding me through the process from idea to artifact. I
would be remiss if I did not also single out Gail Hornstein for agreeing to
include her unique bibliography of first-person narratives of madness in
this volume. Finally, as in most everything in my life, Natascha Hoffmeyer
has been a vital source of advice and support.
From Madness to Mental Health
page xvi is blank.
 Introduction
More than perhaps any other set of human afflictions, the phenomena that
have gone under the names of “madness,” “insanity,” “lunacy,” and “men-
tal illness” have historically provoked a wide variety of often contradictory
reactions. Those who have been in the throes of “madness” have described
experiences ranging from enjoying an ecstatic sense of holiness to being
beset by undeniable impulses to having feelings of unending despair.
Observers have sought explanations for the behavior of “touched” and
“crazy” individuals by invoking such things as sin, destiny, heredity, moral
degeneracy, upbringing, trauma, fatigue, and body chemistry. Those
afflicted have been admired, pitied, mocked, hidden from public view, can-
onized, imprisoned, restrained, operated on, sterilized, hospitalized, killed,
counseled, analyzed, and medicated. Why?
This volume is an introductory anthology about the history of madness
and its treatment in Western civilization. In part, it is meant to serve as a
companion to Rutgers University Press’s Medicine and Western Civilization
(edited by David J. Rothman, Steven Marcus, and Stephanie A. Kiceluk),
with the main focus here being scientific and clinical understandings. But
attention is also paid to attitudes expressed in theology, art, philosophy, the
social sciences, politics, and law, as well as to the perspectives of those
directly affected by madness or mental illness.
Rather than provide a broad historical narrative, in this book I present
a collection of important and representative historical texts and images that
shed light on the development of Western approaches to mental health.
Primary sources are an ideal way to both teach and learn about human
experiences such as madness that seem to defy simple description and
explanation. Rather than reflecting a position on whether insanity is spiri-
tual, social, or biological in origin or whether a given individual was

1
2 — Introduction
mentally ill, the documents presented here are meant to inspire interpreta-
tion, discussion, and debate about how madness has historically been imag-
ined, talked about, and handled. In this sense, madness and mental illness
are treated here as what the sociologist Emile Durkheim called “social
facts”—that is, as concepts, roles, and experiences that societies have rec-
ognized as real and important, even if we today might not.
It is probably safe to say that every society has recognized the existence
of something we now generally refer to as “mental illness.” That said, the
form, substance, and public perception and treatment of that experience
have differed greatly over time. To be sure, the history of madness and its
treatment in Western society is marked by noteworthy continuities. For
instance, the ideas of Hippocrates and Galen influenced medical thinking
well into early modern times. But the history of madness also has been
punctuated by ruptures and rapid change. One need only look at the late
nineteenth century or the late twentieth, when brain science radically
altered how people accounted for and treated insanity.
The story of the West’s encounter with madness has proved difficult
for historians to plot out as one of ever-advancing progress. For centuries,
contemporary observers have regularly complained about how ineffective
cures have been. And since the late eighteenth century, many have held the
view that the prevalence of mental illness actually has increased, rather than
decreased, with the passage of time. In addition, it has not escaped the
notice of clinicians, scholars, and the lay public that some of what we today
might consider among the most ethically questionable forms of treat-
ment—malaria fever therapy, insulin coma therapy, lobotomy, sterilization,
euthanasia—were invented and applied only in recent times.
The long history of madness in Western civilization, therefore, cannot
be easily characterized as a tale of the gradual triumph of enlightened
knowledge. By the same merit, however, it is essential to recognize the
good faith and often successful efforts that have been made at compre-
hending and alleviating the human misery associated with mental illness.
Clinicians, caretakers, policymakers, philosophers, theologians, novelists,
journalists, and the afflicted themselves—a wide array of professionals and
laypeople have wrestled with making sense of madness as a human predica-
ment. In this, they frequently have shown notable insight and compassion.
Of course today, there are prominent individuals and organizations
that claim that psychiatry and clinical psychology are pseudosciences, their
 Introduction —3
histories consisting of little more than abuse and torture. Others, on the
other hand, proclaim the supremacy of biological psychiatry and disparage
any outlook that refuses to accept that madness is anything other than a
brain disorder. Such contentiousness appears to be an emblematic feature
of our society today. From a historical vantage point, however, it is striking
to note that arguments like these actually date back centuries. And beyond
the matter of who is right and who is wrong, impassioned debates such as
these raise an interesting question: Why does madness seem to compel us
to revisit the same issues over and over again?
For its part, From Madness to Mental Health has the aim of neither glori-
fying nor denigrating the contribution of psychiatry, clinical psychology,
and psychotherapy (there is ample evidence here to encourage both
prospects). Rather, in the volume I approach madness as a historical phe-
nomenon that has sparked a variety of interpretations from sufferers and
observers alike. At its heart, madness is an existential matter, meaning
that it prompts us to pose fundamental questions about who we are, what
makes us human, what constitutes a normal life, and the degree to which
we are the authors of that life. Studying the history of madness, then, does
not only mean studying deviant ways of perceiving, thinking, and acting.
Rather, it is also an exercise in self-exploration, a way of holding up a mir-
ror to ourselves and seeing how we human beings have valued our bodies,
minds, and souls.
By and large, the documents in this volume are organized chronologi-
cally. The title, From Madness to Mental Health, not only refers to the gen-
eral effort at bringing those deemed insane to a state of relative sanity; it
also points to a historical shift from a longtime professional and societal
focus on treating severe cases to a more recent focus on promoting the
mental well-being of a wide range of individuals. To put it simply, you do
not need to be suffering from a mental illness today to call on the know-
how of mental health experts.
Over time, certain currents and trends have underscored particular
moments in the history of madness. For this reason, the chronology is
divided into four major epochs, each characterized by what could be seen
as a prevailing attitude or feature of the time. The first and lengthiest
period, stretching from the ancient to the early modern, was one in which
madness was widely considered to be both material and immaterial, spiri-
tual and somatic in nature. The second period, running from the late
4 — Introduction
eighteenth to the turn of the twentieth century, was a time in which opti-
mistic reformers came to believe in the real possibility of understanding the
causes of maladies, discovering cures, and unlocking the full potential of
psychiatry. Under the influence of the rise of extreme political ideologies
and the two world wars, a third period saw a heightened sense of militancy
that helped encourage daring attempts to radically reconceive mental illness
and its treatment. Finally, beginning around the middle of the past century,
there emerged a period marked by a pronounced expansion and growth in
clinical psychology, psychotherapy, and psychopharmacology.
No selection of readings covering such a lengthy period of time could
possibly be comprehensive. The emphasis here is on the eighteenth cen-
tury and after, the period during which “mad-doctors” became profes-
sionalized as “psychiatrists” and “clinical psychologists,” new asylums
and psychiatric clinics were built, and science took on an increasingly
important role in shaping how madness was understood and treated.
Admittedly, there are glaring absences. Some (such as Ugo Cerletti)
result from the fact that copyright permission fees were simply too
costly; in other cases (such as William Shakespeare or more recent first-
person narratives), versions are readily available elsewhere. In the end,
choices have been made that will likely disappoint someone. But the
point here is not to attempt to be exhaustive—something that would be
impossible anyway—but rather to see a collection such as this as the
beginning of an encounter with the history of madness, mental illness,
and their treatment.
In the choice of texts and images, emphasis has been placed on explor-
ing three broad dimensions in the history of madness and its treatment:

the intellectual history of madness and mental illness: these are texts
that present influential medical, religious, philosophical, scientific,
legal, and lay notions about the nature and treatment of mental
disorders.
the social and institutional history of madness and mental illness: these
are sources that explore the ways in which communities and public
institutions have handled the mad and mentally ill.
the experiential history of madness and mental illness: these are personal
narratives detailing how individuals have experienced madness and
its treatment over time.
 Introduction —5
Admittedly, direct personal stories make up the smaller share of the
sources here. But it should be pointed out that the voices of the afflicted can
often be heard within and reconstructed from many of the conventional
clinical documents presented here. Case histories, for instance, often pro-
vide surprising insight into the tensions and differences between patients
and their caretakers. As a reference aid for interested readers, however, a
list of first-person narratives about mental illness—put together by Gail A.
Hornstein—is provided at the end of this volume.
page 6 is blank.
PART I

The Pneumatic Age

From ancient times until well into the eighteenth century,
observers, victims, and healers of madness most often under-
stood and treated it as both a physical and metaphysical malady.
This was because it was widely believed that human rationality,
passions, and desires had at once somatic and spiritual dimen-
sions. In ancient Greece, for instance, Plato held that different
kinds of psyche, or “soul,” animated organs such as the brain,
liver, and heart, while Aristotle equated psyche with the very
workings of organs. Meanwhile, physicians generally accepted
that the human body was composed of the four “humors” of
blood, phlegm, yellow bile, and black bile and that health and
sickness were the result of some kind of imbalance in their dis-
tribution. In turn, the humors were believed to be influenced by
the four fundamental elements that composed the universe (fire,
air, water, earth). By the second and third centuries C.E., West-
ern medical scholars were arguing that vital pneuma (literally
“breath” or “wind” in Greek) served as the essential intermedi-
ary between the immaterial soul and material organs. These
notions continued to inform scholarly and medical thought
throughout the Middle Ages (500–1500) and the early modern
period (1500–1800).
Madness, however, also carried social and moral meanings.
While the mad were first shut up in institutions only in the
fourteenth and fifteenth centuries, they were widely feared,
ridiculed, and pitied for their apparent foolishness and unpre-
dictable behavior. Relatives or friends were the obvious and pri-
mary caretakers for most. But for those who were chronically

7
8 — The Pneumatic Age

insane and lacking such support, their care often fell to religious
orders and local municipalities, who housed them in a variety of
hospices, hospitals, infirmaries, poorhouses, and retreats well
into the nineteenth century. Christians, especially, often raised
questions about whether, for instance, chronic epilepsy or
“idiocy” (an antiquated term for mental retardation) might have
been a fate bestowed on a person for a sin committed by the suf-
ferer or his or her family. And right up to modern times, it was
not uncommon for charms, amulets, relics, and holy waters to be
used to treat and ward off insanity.
Religion thus has played a critical role in the history of mad-
ness. Pagan, Jewish, Christian, and Muslim traditions all recog-
nized links, but also boundaries, between expressions of
prophecy or devotional ecstasy and madness. And, in fact, reli-
gious groups borrowed heavily from one another’s worldviews,
as in the case of Saint Paul, who adopted the term pneuma and
applied it to the early Christian concept of the Holy Spirit.
Dating back to ancient times, madness and folly (in Latin,
insania or stultitia) were broad cultural notions. One could apply
the terms quite casually to an individual’s conduct—“Oh, he
must be mad!” or “Look at the old fool!”—without implying the
presence of an actual medical disease. The cultural currency of
madness allowed poets, essayists, and playwrights to use the fig-
ure of the fool to criticize their contemporaries, giving a fool’s
voice to common deceptions (as in Sebastian Brant’s Ship of Fools)
or having a fool express uncommon wisdom (as in Shakespeare’s
plays).
These more informal notions clearly inflected and were
inflected by legal and medical points of view. Ancient, medieval,
and early modern legal systems all considered the chronically
insane to be deprived of reason and, therefore, incapable of enter-
ing into contracts or assuming criminal responsibility. Distinc-
tions were drawn, however, between those afflicted by temporary
bouts of madness and those constantly under its sway. In this
regard, idiocy was understood to be a categorically different phe-
 The Pneumatic Age —9

nomenon from insanity, in that the former was believed to be a

congenital defect.
While there was no universally accepted manual for classify-
ing forms of madness before the twentieth century, ancient,
medieval, and early modern physicians did generally agree on
there being three classic types of madness: phrenitis, or frenzy
(an acute disease associated with delirium); melancholy (a
chronic affliction associated with fear, anxiety, and sadness); and
mania (another chronic disturbance, characterized by excite-
ment, delusions, and anxiety). A fourth prominent malady, hys-
teria—thought to chiefly affect women and characterized by
dissociation, paralyses, and the loss of various motor skills—was
often subsumed under the category of a mania. Medical remedies
tended to be whole-body cures (such as throwing a patient into
a raging sea), rather than localized treatments, since it was con-
sidered essential to restore an equilibrium between the humors.
By the end of the eighteenth century, however, humoral medi-
cine was being challenged by scholars who believed that electric-
ity, not fluids, held the key to the human nervous system.
 The Ancient World

The Bible, 1 Samuel

(ca. 960 b.c.e.)

Saul was the first king of Israel, reigning between roughly 1020 and
1000 B.C.E. Comparatively little is known about his reign, though
he was renowned for leading the Israelites in war against their ene-
mies the Philistines. The Bible devotes a great deal of time to
recounting Saul’s jealousy of and conflict with his son-in-law and
future successor, David. The extent to which the account in Samuel
is accurate is, at the very least, difficult to assess. From the stand-
point of the history of madness, however, the story of Saul’s erratic
behavior and his volatile relationship with David provides a glimpse
into how the ancient Israelites recognized there to be links and
boundaries between religious experience and madness. As the text
repeats several times, “Is Saul also among the prophets?”

1 Samuel 10

1 Then Samuel took a vial of oil and poured it on his [Saul’s] head, and
kissed him and said, “Has not the lord anointed you to be prince over
his people Israel? And you shall reign over the people of the lord and
you will save them from the hand of their enemies round about. And
this shall be the sign to you that the lord has anointed you to be
prince over his heritage.

10
 The Bible, I Samuel — 11
2 When you depart from me today you will meet two men by Rachel’s
tomb in the territory of Benjamin at Zelzah, and they will say to you,
‘The asses which you went to seek are found, and now your father has
ceased to care about the asses and is anxious about you, saying, “What
shall I do about my son?”’
3 Then you shall go on from there further and come to the oak of Tabor;
three men going up to God at Bethel will meet you there, one carrying
three kids, another carrying three loaves of bread, and another carry-
ing a skin of wine.
4 And they will greet you and give you two loaves of bread, which you
shall accept from their hand.
5 After that you shall come to Gib’e-ath-elo’him, where there is a garri-
son of the Philistines; and there, as you come to the city, you will meet
a band of prophets coming down from the high place with harp, tam-
bourine, flute, and lyre before them, prophesying.
6 Then the spirit of the lord will come mightily upon you, and you
shall prophesy with them and be turned into another man.
7 Now when these signs meet you, do whatever your hand finds to do,
for God is with you.
8 And you shall go down before me to Gilgal; and behold, I am coming to
you to offer burnt offerings and to sacrifice peace offerings. Seven days
you shall wait, until I come to you and show you what you shall do.”
9 When he turned his back to leave Samuel, God gave him another
heart; and all these signs came to pass that day.
10 When they came to Gib’e-ah, behold, a band of prophets met him; and
the spirit of God came mightily upon him, and he prophesied among
them.
11 And when all who knew him before saw how he prophesied with the
prophets, the people said to one another, “What has come over the
son of Kish? Is Saul also among the prophets?”
12 And a man of the place answered, “And who is their father?” There-
fore it became a proverb, “Is Saul also among the prophets?”

1 Samuel 15

1 And Samuel said to Saul, “The lord sent me to anoint you king over
his people Israel; now therefore hearken to the words of the lord.
12 — The Ancient World
2 Thus says the lord of hosts, ‘I will punish what Am’alek did to Israel
in opposing them on the way, when they came up out of Egypt.
3 Now go and smite Am’alek, and utterly destroy all that they have; do
not spare them, but kill both man and woman, infant and suckling, ox
and sheep, camel and ass.’”
4 So Saul summoned the people, and numbered them in Tela’im, two
hundred thousand men on foot, and ten thousand men of Judah.
5 And Saul came to the city of Am’alek, and lay in wait in the valley.
6 And Saul said to the Ken’ites, “Go, depart, go down from among the
Amal’ekites, lest I destroy you with them; for you showed kindness to
all the people of Israel when they came up out of Egypt.” So the
Ken’ites departed from among the Amal’ekites.
7 And Saul defeated the Amal’ekites, from Hav’ilah as far as Shur, which
is east of Egypt.
8 And he took Agag the king of the Amal’ekites alive, and utterly
destroyed all the people with the edge of the sword.
9 But Saul and the people spared Agag, and the best of the sheep and of
the oxen and of the fatlings, and the lambs, and all that was good, and
would not utterly destroy them; all that was despised and worthless
they utterly destroyed.
10 The word of the lord came to Samuel:
11 “I repent that I have made Saul king; for he has turned back from fol-
lowing me, and has not performed my commandments.” And Samuel
was angry; and he cried to the lord all night.
12 And Samuel rose early to meet Saul in the morning; and it was told
Samuel, “Saul came to Carmel, and behold, he set up a monument for
himself and turned, and passed on, and went down to Gilgal.”
13 And Samuel came to Saul, and Saul said to him, “Blessed be you to the
lord; I have performed the commandment of the lord.”
14 And Samuel said, “What then is this bleating of the sheep in my ears,
and the lowing of the oxen which I hear?”
15 Saul said, “They have brought them from the Amal’ekites; for the peo-
ple spared the best of the sheep and of the oxen, to sacrifice to the
lord your God; and the rest we have utterly destroyed.”
16 Then Samuel said to Saul, “Stop! I will tell you what the lord said to
me this night.” And he said to him, “Say on.”
17 And Samuel said, “Though you are little in your own eyes, are you not
 The Bible, I Samuel — 13
the head of the tribes of Israel? The lord anointed you king over
Israel.
18 And the lord sent you on a mission, and said, ‘Go, utterly destroy
the sinners, the Amal’ekites, and fight against them until they are
consumed.’
19 Why then did you not obey the voice of the lord? Why did you
swoop on the spoil, and do what was evil in the sight of the lord?”
20 And Saul said to Samuel, “I have obeyed the voice of the lord, I have
gone on the mission on which the lord sent me, I have brought Agag
the king of Am’alek, and I have utterly destroyed the Amal’ekites.
21 But the people took of the spoil, sheep and oxen, the best of the things
devoted to destruction, to sacrifice to the lord your God in Gilgal.”
22 And Samuel said, “Has the lord as great delight in burnt offerings
and sacrifices, as in obeying the voice of the lord? Behold, to obey is
better than sacrifice, and to hearken than the fat of rams.
23 For rebellion is as the sin of divination, and stubbornness is as iniquity
and idolatry. Because you have rejected the word of the lord, he has
also rejected you from being king.”
24 And Saul said to Samuel, “I have sinned; for I have transgressed the
commandment of the lord and your words, because I feared the peo-
ple and obeyed their voice.
25 Now therefore, I pray, pardon my sin, and return with me, that I may
worship the lord.”
26 And Samuel said to Saul, “I will not return with you; for you have
rejected the word of the lord, and the lord has rejected you from
being king over Israel.”
27 As Samuel turned to go away, Saul laid hold upon the skirt of his robe,
and it tore.
28 And Samuel said to him, “The lord has torn the kingdom of Israel
from you this day, and has given it to a neighbor of yours, who is bet-
ter than you.
29 And also the Glory of Israel will not lie or repent; for he is not a man,
that he should repent.”
30 Then he said, “I have sinned; yet honor me now before the elders of
my people and before Israel, and return with me, that I may worship
the lord your God.”
31 So Samuel turned back after Saul; and Saul worshiped the lord.
14 — The Ancient World
32 Then Samuel said, “Bring here to me Agag the king of the
Amal’ekites.” And Agag came to him cheerfully. Agag said, “Surely
the bitterness of death is past.”
33 And Samuel said, “As your sword has made women childless, so shall
your mother be childless among women.” And Samuel hewed Agag in
pieces before the lord in Gilgal.
34 Then Samuel went to Ramah; and Saul went up to his house in Gib’e-
ah of Saul.
35 And Samuel did not see Saul again until the day of his death, but
Samuel grieved over Saul. And the lord repented that he had made
Saul king over Israel.

1 Samuel 16

1 The lord said to Samuel, “How long will you grieve over Saul, seeing
I have rejected him from being king over Israel? Fill your horn with oil,
and go; I will send you to Jesse the Bethlehemite, for I have provided
for myself a king among his sons.”
2 And Samuel said, “How can I go? If Saul hears it, he will kill me.” And
the lord said, “Take a heifer with you, and say, ‘I have come to sacri-
fice to the lord.’
3 And invite Jesse to the sacrifice, and I will show you what you shall do;
and you shall anoint for me him whom I name to you.”
4 Samuel did what the lord commanded, and came to Bethlehem. The
elders of the city came to meet him trembling, and said, “Do you come
peaceably?”
5 And he said, “Peaceably; I have come to sacrifice to the lord; con-
secrate yourselves, and come with me to the sacrifice.” And he conse-
crated Jesse and his sons, and invited them to the sacrifice.
6 When they came, he looked on Eli’ab and thought, “Surely the
lord’s anointed is before him.”
7 But the lord said to Samuel, “Do not look on his appearance or on
the height of his stature, because I have rejected him; for the lord sees
not as man sees; man looks on the outward appearance, but the lord
looks on the heart.”
8 Then Jesse called Abin’adab, and made him pass before Samuel. And
he said, “Neither has the lord chosen this one.”
 The Bible, I Samuel — 15
9 Then Jesse made Shammah pass by. And he said, “Neither has the
lord chosen this one.”
10 And Jesse made seven of his sons pass before Samuel. And Samuel said
to Jesse, “The lord has not chosen these.”
11 And Samuel said to Jesse, “Are all your sons here?” And he said,
“There remains yet the youngest, but behold, he is keeping the
sheep.” And Samuel said to Jesse, “Send and fetch him; for we will not
sit down till he comes here.”
12 And he sent, and brought him in. Now he was ruddy, and had beauti-
ful eyes, and was handsome. And the lord said, “Arise, anoint him;
for this is he.”
13 Then Samuel took the horn of oil, and anointed him in the midst of
his brothers; and the Spirit of the lord came mightily upon David
from that day forward. And Samuel rose up, and went to Ramah.
14 Now the Spirit of the lord departed from Saul, and an evil spirit from
the lord tormented him.
15 And Saul’s servants said to him, “Behold now, an evil spirit from God
is tormenting you.
16 Let our lord now command your servants, who are before you, to seek
out a man who is skilful in playing the lyre; and when the evil spirit
from God is upon you, he will play it, and you will be well.”
17 So Saul said to his servants, “Provide for me a man who can play well,
and bring him to me.”
18 One of the young men answered, “Behold, I have seen a son of Jesse the
Bethlehemite, who is skilful in playing, a man of valor, a man of war, pru-
dent in speech, and a man of good presence; and the lord is with him.”
19 Therefore Saul sent messengers to Jesse, and said, “Send me David
your son, who is with the sheep.”
20 And Jesse took an ass laden with bread, and a skin of wine and a kid,
and sent them by David his son to Saul.
21 And David came to Saul, and entered his service. And Saul loved him
greatly, and he became his armor-bearer.
22 And Saul sent to Jesse, saying, “Let David remain in my service, for he
has found favor in my sight.”
23 And whenever the evil spirit from God was upon Saul, David took the
lyre and played it with his hand; so Saul was refreshed, and was well,
and the evil spirit departed from him.
16 — The Ancient World
1 Samuel 18

5 And David went out and was successful wherever Saul sent him; so
that Saul set him over the men of war. And this was good in the sight
of all the people and also in the sight of Saul’s servants.
6 As they were coming home, when David returned from slaying the
Philistine, the women came out of all the cities of Israel, singing and
dancing, to meet King Saul, with timbrels, with songs of joy, and with
instruments of music.
7 And the women sang to one another as they made merry, “Saul has
slain his thousands, and David his ten thousands.”
8 And Saul was very angry, and this saying displeased him; he said,
“They have ascribed to David ten thousands, and to me they have
ascribed thousands; and what more can he have but the kingdom?”
9 And Saul eyed David from that day on.
10 And on the morrow an evil spirit from God rushed upon Saul, and he
raved within his house, while David was playing the lyre, as he did day
by day. Saul had his spear in his hand;
11 and Saul cast the spear, for he thought, “I will pin David to the wall.”
But David evaded him twice.
12 Saul was afraid of David, because the lord was with him but had
departed from Saul.

1 Samuel 19

9 Then an evil spirit from the lord came upon Saul, as he sat in his
house with his spear in his hand; and David was playing the lyre.
10 And Saul sought to pin David to the wall with the spear; but he eluded
Saul, so that he struck the spear into the wall. And David fled, and
escaped.
11 That night Saul sent messengers to David’s house to watch him, that
he might kill him in the morning. But Michal, David’s wife, told him,
“If you do not save your life tonight, tomorrow you will be killed.”
12 So Michal let David down through the window; and he fled away and
escaped.
13 Michal took an image and laid it on the bed and put a pillow of goats’
hair at its head, and covered it with the clothes.
 The Bible, I Samuel — 17
14 And when Saul sent messengers to take David, she said, “He is sick.”
15 Then Saul sent the messengers to see David, saying, “Bring him up to
me in the bed, that I may kill him.”
16 And when the messengers came in, behold, the image was in the bed,
with the pillow of goats’ hair at its head.
17 Saul said to Michal, “Why have you deceived me thus, and let my
enemy go, so that he has escaped?” And Michal answered Saul, “He
said to me, ‘Let me go; why should I kill you?’”
18 Now David fled and escaped, and he came to Samuel at Ramah, and
told him all that Saul had done to him. And he and Samuel went and
dwelt at Nai’oth.
19 And it was told Saul, “Behold, David is at Nai’oth in Ramah.”
20 Then Saul sent messengers to take David; and when they saw the com-
pany of the prophets prophesying, and Samuel standing as head over
them, the Spirit of God came upon the messengers of Saul, and they
also prophesied.
21 When it was told Saul, he sent other messengers, and they also proph-
esied. And Saul sent messengers again the third time, and they also
prophesied.
22 Then he himself went to Ramah, and came to the great well that is in
Secu; and he asked, “Where are Samuel and David?” And one said,
“Behold, they are at Nai’oth in Ramah.”
23 And he went from there to Nai’oth in Ramah; and the Spirit of God
came upon him also, and as he went he prophesied, until he came to
Nai’oth in Ramah.
24 And he too stripped off his clothes, and he too prophesied before
Samuel, and lay naked all that day and all that night. Hence it is said,
“Is Saul also among the prophets?”

From The Common Bible: Revised Standard Version, http:/quod.lib.umich.edu/rlrsv,

copyright 1973 by the Division of Christian Education of the National Council of
the Churches of Christ in the United States of America. Used by permission. All
rights reserved.
18 — The Ancient World

Euripides
(484–407/6 B.C.E.)

The Bacchae
(ca. 404 B.C.E.)

Euripides was considered one of the great tragic poets of fifth-cen-

tury B.C.E. Greece. While little is known about his personal life and
intellectual background, we do know that he was prolific (scholars
in Alexandria later attributed eighty-eight plays to him) and that he
won five different tragic competitions over the course of his life. It
is said that upon hearing news of Euripides’ death, the famed
Sophocles publicly mourned.
As Greek mythology tells it, Dionysus (also known as Bacchus)
was the illegitimate offspring of Zeus (king of the gods) and Semele
(a Theban princess). According to the myth, Semele’s boasting of
the pregnancy led Zeus’s wife, Hera, and Semele’s sisters to become
jealous, ultimately leading Hera to kill Semele and her sisters to
speak ill about Semele after her death. The Bacchae tells the story of
the return of the hedonistic Dionysus to Thebes in order to punish
Semele’s sisters as well as to introduce the city to his new religion.
As we join the play, the women of Thebes—including Semele’s sis-
ter Agave, the daughter of former king Cadmus and mother to the
present king, Pentheus—are in the throes of Dionysian ecstasy. In
the ancient world, ecstatic states and behavior were associated with
both religious devotion and madness, as this excerpt shows.

chorus: Speak to me, tell all—

How did death strike him down,
that unrighteous man,
that man who acted so unjustly?

second messenger: Once we’d left the settlements of Thebes,

we went across the river Asopus,
then started the climb up Mount Cithaeron—
 Euripides, The Bacchae — 19

A representation of the mythical Thracian king Lykurgos. Lykurgos, it was

said, tried to prevent the spread of the Dionysian cult in his kingdom. In
response, Dionysus drove the king mad; the king then killed his own son,
believing him to be a vine. From Herculaneum. Museo Archeologico
Nazionales, Naples, Italy. © Erich Lessing/Art Resource, NY.

Pentheus and myself, I following the king.

The stranger was our guide, scouting the way.
First, we sat down in a grassy meadow,
keeping our feet and tongues quite silent,
so we could see without being noticed.
There was a valley there shut in by cliffs.
Through it refreshing waters flowed, with pines
providing shade. The Maenads sat there,
their hands all busy with delightful work—
20 — The Ancient World
some of them with ivy strands repairing
damaged thyrsoi, while others sang,
chanting Bacchic songs to one another,
carefree as fillies freed from harness.
Then Pentheus, that unhappy man,
not seeing the crowd of women, spoke up,
“Stranger, I can’t see from where we’re standing.
My eyes can’t glimpse those crafty Maenads.
But up there, on that hill, a pine tree stands.
If I climbed that, I might see those women,
and witness the disgraceful things they do.”
Then I saw that stranger work a marvel.
He seized that pine tree’s topmost branch—
it stretched up to heaven—and brought it down,
pulling it to the dark earth, bending it
as if it were a bow or some curved wheel
forced into a circle while staked out with pegs—
that’s how the stranger made that tree bend down,
forcing the mountain pine to earth by hand,
something no mortal man could ever do.
He set Pentheus in that pine tree’s branches.
Then his hands released the tree, but slowly,
so it stood up straight, being very careful
not to shake Pentheus loose. So that pine
towered straight up to heaven, with my king
perched on its back. Maenads could see him there
more easily than he could spy on them.
As he was just becoming visible—
the stranger had completely disappeared—
some voice—I guess it was Dionysus—
cried out from the sky, “Young women,
I’ve brought you the man who laughed at you,
who ridiculed my rites. Now punish him!”
As he shouted this, a dreadful fire arose,
blazing between the earth and heaven.
The air was still. In the wooded valley
no sound came from the leaves, and all the beasts
 Euripides, The Bacchae — 21
were silent, too. The women stood up at once.
They’d heard the voice, but not distinctly.
They gazed around them. Then again the voice
shouted his commands. When Cadmus’ daughters
clearly heard what Dionysus ordered,
they rushed out, running as fast as doves,
moving their feet at an amazing speed.
His mother Agave with both her sisters
and all the Bacchae charged straight through
the valley, the torrents, the mountain cliffs,
pushed to a god-inspired frenzy.
They saw the king there sitting in that pine.
First, they scaled a cliff face looming up
opposite the tree and started throwing rocks,
trying to hurt him. Others threw branches,
or hurled their thyrsoi through the air at him,
sad, miserable Pentheus, their target.
But they didn’t hit him. The poor man
sat high beyond their frenzied cruelty,
trapped up there, no way to save his skin.
Then, like lightning, they struck oak branches down,
trying them as levers to uproot the tree.
When these attempts all failed, Agave said,
“Come now, make a circle round the tree.
Then, Maenads, each of you must seize a branch,
so we can catch the climbing beast up there,
stop him making our god’s secret dances known.”
Thousands of hands grabbed the tree and pulled.
They yanked it from the ground. Pentheus fell,
crashing to earth down from his lofty perch,
screaming in distress. He knew well enough
something dreadful was about to happen.
His priestess mother first began the slaughter.
She hurled herself at him. Pentheus tore off
his headband, untying it from his head,
so wretched Agave would recognize him,
so she wouldn’t kill him. Touching her cheek,
22 — The Ancient World
he cried out, “It’s me, mother, Pentheus,
your child. You gave birth to me at home,
in Echion’s house. Pity me, mother—
don’t kill your child because I’ve made mistakes.”
But Agave was foaming at the mouth,
eyes rolling in their sockets, her mind not set
on what she ought to think—she didn’t listen—
she was possessed, in a Bacchic frenzy.
She seized his left arm, below the elbow,
pushed her foot against the poor man’s ribs,
then tore his shoulder out. The strength she had—
it was not her own. The god put power
into those hands of hers. Meanwhile Ino,
her sister, went at the other side,
ripping off chunks of Pentheus’ flesh,
while Autonoe and all the Bacchae,
the whole crowd of them, attacked as well,
all of them howling out together.
As long as Pentheus was still alive,
he kept on screaming. The women cried in triumph—
one brandished an arm, another held a foot—
complete with hunting boot—the women’s nails
tore his ribs apart. Their hands grew bloody,
tossing bits of his flesh back and forth, for fun.
His body parts lie scattered everywhere—
some under rough rocks, some in the forest,
deep in the trees. They’re difficult to find.
As for the poor victim’s head, his mother
stumbled on it. Her hands picked it up,
then stuck it on a thyrsus, at the tip.
Now she carries it around Cithaeron,
as though it were some wild lion’s head.
She’s left her sisters dancing with the Maenads.
She’s coming here, inside these very walls,
showing off with pride her ill-fated prey,
calling out to her fellow hunter, Bacchus,
her companion in the chase, the winner,
 Euripides, The Bacchae — 23
the glorious victor. By serving him,
in her great triumph she wins only tears.
As for me, I’m leaving this disaster,
before Agave gets back home again.
The best thing is to keep one’s mind controlled,
and worship all that comes down from the gods.
That, in my view, is the wisest custom,
for those who can conduct their lives that way.

[Exit Messenger]

chorus: Let’s dance to honour Bacchus,

Let’s shout to celebrate what’s happened here,
happened to Pentheus,
child of the serpent,
who put on women’s clothes,
who took up the beautiful and blessed thyrsus—
his certain death,
disaster brought on by the bull.
You Bacchic women
descended from old Cadmus,
you’ve won glorious victory,
one which ends in tears,
which ends in lamentation.
A noble undertaking this,
to drench one’s hands in blood,
life blood dripping from one’s only son.

chorus leader: Wait! I see Agave, Pentheus’ mother,

on her way home, her eyes transfixed.
Let’s now welcome her,
the happy revels of our god of joy!

[Enter Agave, cradling the head of Pentheus]

agave: Asian Bacchae . . .

chorus: Why do you appeal to me?

agave: [displaying the head] From the mountains I’ve brought home
this ivy tendril freshly cut.
24 — The Ancient World
We’ve had a blessed hunt.

chorus: I see it.

As your fellow dancer, I’ll accept it.

agave: I caught this young lion without a trap,

as you can see.

chorus: What desert was he in?

agave: Cithaeron.

chorus: On Cithaeron?

agave: Cithaeron killed him.

chorus: Who struck him down?

agave: The honour of the first blow goes to me.

In the dancing I’m called blessed Agave.

chorus: Who else?

agave: Well, from Cadmus . . .

chorus: From Cadmus what?

agave: His other children laid hands on the beast,

but after me—only after I did first.
We’ve had good hunting. So come, share our feast.

chorus: What? You want me to eat that with you?

Oh you unhappy woman.

agave: This is a young bull. Look at this cheek

It’s just growing downy under the crop
of his soft hair.

chorus: His hair makes him resemble

some wild beast.

agave: Bacchus is a clever huntsman—

he wisely set his Maenads on this beast.

chorus: Yes, our master is indeed a hunter.

 Euripides, The Bacchae — 25
agave: Have you any praise for me?

chorus: I praise you.

agave: Soon all Cadmus’ people . . .

chorus: . . . and Pentheus, your son, as well.

agave: . . . will celebrate his mother, who caught the beast,

just like a lion.

chorus: It’s a strange trophy.

agave: And strangely captured, too.

chorus: You’re proud of what you’ve done?

agave: Yes, I’m delighted. Great things I’ve done—

great things on this hunt, clear for all to see.

chorus: Well then, you most unfortunate woman,

show off your hunting prize, your sign of victory,
to all the citizens.

agave: [addressing everyone] All of you here,

all you living in the land of Thebes,
in this city with its splendid walls,
come see this wild beast we hunted down—
daughters of Cadmus—not with thonged spears,
Thessalian javelins, or by using nets,
but with our own white hands, our finger tips.
After this, why should huntsmen boast aloud,
when no one needs the implements they use?
We caught this beast by hand, tore it apart—
with our own hands. But where’s my father?
He should come here. And where’s Pentheus?
Where is my son? He should take a ladder,
set it against the house, fix this lion’s head
way up there, high on the palace front.
I’ve captured it and brought it home with me.

[Enter Cadmus and attendants, carrying parts of Pentheus’ body]

26 — The Ancient World
cadmus: Follow me, all those of you who carry
some part of wretched Pentheus. You slaves,
come here, right by the house.

[They place the bits of Pentheus’ body together in a chest front of the palace]

I’m worn out.

So many searches—but I picked up the body.
I came across it in the rocky clefts
on Mount Cithaeron, ripped to pieces,
no parts lying together in one place.
It was in the woods—difficult to search.
Someone told me what my daughter’d done,
those horrific acts, once I’d come back,
returning here with old Tiresias,
inside the city walls, back from the Bacchae.
So I climbed the mountains once again.
Now I bring home this child the Maenads killed.
I saw Autonoe, who once bore
Actaeon to Aristeius—and Ino,
she was with her there, in the forest,
both still possessed, quite mad, poor creatures.
Someone said Agave was coming here,
still doing her Bacchic dance. He spoke the truth,
for I see her there—what a wretched sight!

agave: Father, now you can be truly proud.

Among all living men you’ve produced
by far the finest daughters. I’m talking
of all of us, but especially of myself.
I’ve left behind my shuttle and my loom,
and risen to great things, catching wild beasts
with my bare hands. Now I’ve captured him,
I’m holding in my arms the finest trophy,
as you can see, bringing it back home to you,
so it may hang here.

[offering him Pentheus’ head]

 Euripides, The Bacchae — 27
Take this, father
let your hands welcome it. Be proud of it,
of what I’ve caught. Summon all your friends—
have a banquet, for you are blessed indeed,
blessed your daughters have achieved these things.

cadmus: This grief’s beyond measure, beyond endurance.

With these hands of yours you’ve murdered him.
You strike down this sacrificial victim,
this offering to the gods, then invite me,
and all of Thebes, to share a banquet.
Alas—first for your sorrow, then my own.
Lord god Bromius, born into this family,
has destroyed us, acting out his justice,
but too much so.

agave: Why such scowling eyes?

How sorrowful and solemn old men become.
As for my son, I hope he’s a fine hunter,
who copies his mother’s hunting style,
when he rides out with young men of Thebes
chasing after creatures in the wild.
The only thing he seems capable of doing
is fighting with the gods. It’s up to you,
father, to reprimand him for it.
Who’ll call him here into my sight,
so he can see my good luck for himself?

cadmus: Alas! Alas! What dreadful pain you’ll feel

when you recognize what you’ve just done.
If you stay forever in your present state,
you’ll be unfortunate, but you won’t feel
as if you’re suffering unhappiness.

agave: But what in all this is wrong or painful?

cadmus: First, raise your eyes. Look up into the sky.

agave: All right. But why tell me to look up there?

28 — The Ancient World
cadmus: Does the sky still seem the same to you,
or has it changed?

agave: It seems, well, brighter . . .

more translucent than it was before.

cadmus: And your inner spirit—is it still shaking?

agave: I don’t understand what it is you’re asking.

But my mind is starting to clear somehow.
It’s changing . . . it’s not what it was before.

cadmus: Can you hear me? Can you answer clearly?

agave: Yes. But, father, what we discussed before,

I’ve quite forgotten.

cadmus: Then tell me this—

to whose house did you come when you got married?

agave: You gave me to Echion, who, men say,

was one of those who grew from seeds you cast.

cadmus: In that house you bore your husband a child.

What was his name?

agave: His name was Pentheus.

I conceived him with his father.

cadmus: Well then,

this head your hands are holding—whose is it?

agave: It’s a lion’s. That’s what the hunters said.

cadmus: Inspect it carefully. You can do that

without much effort.

agave: [inspecting the head] What is this?

What am I looking at? What am I holding?

cadmus: Look at it. You’ll understand more clearly.

agave: What I see fills me with horrific pain . . .

such agony . . .
 Euripides, The Bacchae — 29
cadmus: Does it still seem to you
to be a lion’s head?

agave: No. It’s appalling—

this head I’m holding belongs to Pentheus.

cadmus: Yes, that’s right. I was lamenting his fate

before you recognized him.

agave: Who killed him?

How did he come into my hands?

cadmus: Harsh truth—

how you come to light at the wrong moment.

agave: Tell me. My heart is pounding in me

to hear what you’re about to say.

cadmus: You killed him—

you and your sisters.

agave: Where was he killed?

At home? In what sort of place?

cadmus: He was killed

where dogs once made a common meal of Actaeon.

agave: Why did this poor man go to Cithaeron?

cadmus: He went there to ridicule the god

and you for celebrating Dionysus.

agave: But how did we happen to be up there?

cadmus: You were insane—the entire city

was in a Bacchic madness.

agave: Now I see.

Dionysus has destroyed us all.

cadmus: He took offense at being insulted.

You did not consider him a god.

agave: Father, where’s the body of my dearest son?

30 — The Ancient World
cadmus: I had trouble tracking the body down.
I brought back what I found.

agave: Are all his limbs laid out

just as they should be? And Pentheus,
what part did he play in my madness?

cadmus: Like you, he was irreverent to the god.

That’s why the god linked you and him together
in the same disaster—thus destroying
the house and me, for I’ve no children left,
now I see this offspring of your womb,
you unhappy woman, cruelly butchered
in the most shameful way. He was the one
who brought new vision to our family.

From Euripides, The Bacchae, translated by Ian Johnston, http://records.viu.ca/

~johnstoi/euripides/euripides.htm. Courtesy of Ian Johnston.

Hippocrates
(ca. 460–377 b.c.e.)

Writings on Hysteria
(ca. fourth century b.c.e.)

Hippocrates was a physician from the Greek island of Cos. Along

with his ancient counterpart Galen (ca. 129 C.E.–ca. 216 C.E.), his
ideas and practices have shaped medicine in the Western world up
to this very day. The writings attributed to him that have been
passed down over the centuries, Corpus Hippocraticum, cover a
range of topics, from diagnosis and prognosis to professional con-
duct. It is now accepted, however, that few of these documents
were written by Hippocrates himself, but rather were the work of
his followers.
 Hippocrates, Writings on Hysteria — 31
Hippocrates’ followers held that disease was the result of an
imbalance within the body of fundamental fluids, referred to as
“humors”: blood, phlegm, and bile. Hippocratic physicians largely
rejected spiritual explanations and treatments, looking instead to
environmental factors, diet, and lifestyle. Inspired by Hippocrates
and others, doctors for centuries after treated afflictions such as
madness in an allopathic manner, that is, applying treatments
designed to have the opposite effect of a given symptom. The
excerpts below discuss the causes and treatment of one of the most
discussed ailments in the history of madness—hysteria, considered
to be primarily a female malady.

Displacement of the Womb

As for what are called women’s diseases: the womb is responsible for all
such diseases. For the womb, when it is displaced from its natural position,
whether forward or back, causes diseases. When the neck of the womb has
been moved back and does not bring its opening towards or touch the lips
of the vagina, the problem is minor. But if the womb falls forward and
brings its opening towards the lips, it first of all causes pain when it makes
contact, and then because the womb is cut off and obstructed by the con-
tact of its neck with the lips of the vagina, there is no so-called menstrual
flow. This flow if retained causes swelling and pain. If the womb descends
and is diverted so that it approaches the groin, it causes pain. If it ascends
and diverted and cut off, it causes illness through its compression. When a
woman is ill because of this problem, she has pains in her thighs and her
head. When the womb is distended and swollen, there is no flow, and it
becomes filled up. When it is filled, it touches the thighs. When the womb
is filled with moisture and distended, there is no flow, and it causes pain in
both the thighs and the groin, something like balls roll through the stom-
ach, and cause pain in the head, first in one part, and then in all of it, as the
disease develops.
The treatment is as follows: if the womb has only moved forward and
it is possible to apply ointment, use any foul-smelling ointment you choose,
either cedar or myssoton, or some other heavy and ill-scented substance,
and fumigate, but do not use a vapour-bath, and do not give food or a
32 — The Ancient World
diuretic liquid during this time, or wash her in hot water. If the womb has
turned upwards and is not obstructed, use sweet-smelling pessaries that are
also inflammatory. These are myrrh, or perfume, or some other aromatic
and inflammatory substance. Use these in pessaries, and from below apply
fumigations with wine vapour, and wash with hot water, and use diuretics.
It is clear that the womb is turned upwards and is not obstructed, because
there is a flow.
If the womb is obstructed, then there is no so-called menstrual flow.
This disease must be treated first with a vapour-bath; put wild figs into
the wine, and heat it and put a gourd around the mouth of the vessel in
which the wine is heated. Then do as follows: cut the gourd through the
middle and hollow it out, and cut off a bit of its top, as if you were mak-
ing a nozzle for a bellows, so that the vapour can go through its channel
and reach the womb. Wash with hot water, and use pessaries made of
inflammatory drugs. The following inflammatory drugs bring on men-
struation: cow dung, beef bile, myrrh, alum, galbanum, and anything sim-
ilar; use as much of these as possible. Evacuate from below by laxative
drugs that do not cause vomiting, diluted, so that it does not become a
purgative by being too strong. Use pessaries as follows, if you want them
to be strong. Use half-cooked honey, and add some of the substances pre-
scribed to bring on menstruation; after you have added them, make the
pessaries like pellets used for the anus, but make them long and thin.
Make the woman lie down, and elevate the feet of the bed towards her
feet, insert the pessary, and apply heat either on a chamber-pot or on
some other vessel, so that the pessary melts. If you want to make the pes-
sary less strong, wrap it in linen. And if the womb is filled with fluid, with
its mouth swollen, so that amenorrhoea results, heal it by bringing on
menstruation with medicinal pessaries, using both inflammatory pes-
saries as described, as in the case of the preceding amenorrhoea. If there
is an excessive flow, do not use hot water or any other kind, nor diuret-
ics or laxative foods. Raise the foot of the bed higher, so that the inclina-
tion of the bed does not encourage the flow, and use astringent pessaries.
The flow, if her period comes directly, is bloody, if it diminishes, it con-
tains pus. Young women bleed more, and the so-called menstrual periods
of older women contain more mucous.
 Hippocrates, Writings on Hysteria — 33
Hysterical Suffocation

When the womb remains in the upper abdomen, the suffocation is similar
to that caused by the purgative hellebore, with stiff breathing and sharp
pains in the heart. Some women spit up acid saliva, and their mouths are
full of fluid, and their legs become cold. In such cases, if the womb does not
leave the upper abdomen directly, the women lose their voices, and their
head and tongue are overcome by drowsiness. If you find such women
unable to speak and with their teeth chattering, insert a pessary of wool,
twisting it round the shaft of a feather in order to get it in as far as possi-
ble—dip it either in white Egyptian perfume or myrtle or bacchar or mar-
joram. Use a spatula to apply black medicine (the kind you use for the
head) to her nostrils. If this is not available, wipe the inside of her nostrils
with silphium, or insert a feather that you have dipped in vinegar, or induce
sneezing. If her mouth is closed tight and she is unable to speak, make her
drink castoreum in wine. Dip your finger in seal oil and wipe inside her nos-
trils. Insert a wool pessary, until the womb returns, and remove it when the
symptoms disappear. But if, when you take the pessary out, the womb
returns to the upper abdomen, insert the pessary as you did before, and
apply beneath her nostrils fumigations of ground-up goat or deer horn, to
which you have added hot ashes, so that they make as much smoke as pos-
sible, and have her inhale the vapour up through her nose as long as she
can stand it. It is best to use a fumigation of seal oil: put the coals in a pot
and wrap the woman up except for her head. So that as much vapour as pos-
sible is emitted, drip a little fat on it, and have her inhale the vapour. She
should keep her mouth shut. This is the procedure if the womb has fallen
upward out of place. . . .
When the womb moves towards her head and suffocation occurs in
that region, the woman’s head becomes heavy, though there are different
symptoms in some cases. One symptom: the woman says the veins in her
nose hurt her and beneath her eyes, and she becomes sleepy, and when this
condition is alleviated, she foams at the mouth.
You should wash her thoroughly with hot water, and if she does not
respond, with cold, from her head on down, using cool water in which you
have previously boiled laurel and myrtle. Rub her head with rose perfume,
and use sweet-scented fumigations beneath her vagina, but foul-scented
ones at her nose. She should eat cabbage, and drink cabbage juice.
34 — The Ancient World
Dislocation of the Womb

If her womb moves towards her hips, her periods stop coming, and pain
develops in her lower stomach and abdomen. If you touch her with your
finger, you will see the mouth of the womb turned towards her hip.
When this condition occurs, wash the woman with warm water, make
her eat as much garlic as she can, and have her drink undiluted sheep’s milk
after her meals. Then fumigate her and give her a laxative. After the laxa-
tive has taken effect, fumigate the womb once again, using a preparation of
fennel and absinthe mixed together. Right after the fumigation, pull the
mouth of the womb with your finger. Then insert a pessary made with
squills; leave it in for a while, and then insert a pessary made with opium
poppies. If you think the condition has been corrected, insert a pessary of
bitter almond oil, and on the next day, a pessary of rose perfume. She
should stop inserting pessaries on the first day of her period, and start again
the day after it stops. The blood during the period provides a normal inter-
ruption. If there is no flow, she should drink four cantharid beetles with
their legs, wings and heads removed, four dark peony seeds, cuttlefish eggs,
and a little parsley seed in wine.* If she has a pain and irregular flow, she
should sit in warm water, and drink honey mixed with water. If she is not
cured by the first procedure, she should drink it again, until her period
comes. When it comes, she should abstain from food and have intercourse
with her husband. During her period she should eat mercury plant and
boiled squid, and keep to soft foods. If she becomes pregnant she will be
cured of this disease. . . .
When her womb moves towards her liver, she suddenly loses her voice
and her teeth chatter and her colouring turns dark. This condition can
occur suddenly, while she is in good health. The problem particularly
affects old maids and widows—young women who have been widowed
after having had children.
When this condition occurs, push your hand down below her liver,
and tie a bandage below her ribs. Open her mouth and pour in very sweet-
scented wine; put applications on her nostrils and burn foul-scented
vapours below her womb. . . .

*Editor’s note: Lefkowitz and Fant note that in ancient times ground-up cantharid
beetles were used as a diuretic as well as to induce menstruation and abortion.
 Hippocrates, Writings on Hysteria — 35
Hysteria in Virgins

As a result of visions, many people choke to death, more women than men,
for the nature of women is less courageous and is weaker. And virgins who
do not take a husband at the appropriate time for marriage experience these
visions more frequently, especially at the time of their first monthly period,
although previously they have had no such bad dreams of this sort. For
later the blood collects in the womb in preparation to flow out; but when
the mouth of the egress is not opened up, and more blood flows into the
womb on account of the body’s nourishment of it and its growth, then the
blood which has no place to flow out, because of its abundance, rushes up
to the heart and to the lungs; and when these are filled with blood, the heart
becomes sluggish, and then, because of the sluggishness, numb, and then,
because of the numbness, insanity takes hold of the woman. Just as when
one has been sitting for a long time the blood that has been forced away
from the hips and the thighs collects in one’s lower legs and feet, it brings
numbness, and as a result of the numbness, one’s feet are useless for move-
ment, until the blood goes back where it belongs. It returns most quickly
when one stands in cold water and wets the tops of one’s ankles. This
numbness presents no complications, since the blood flows back quickly
because the veins in that part of the body are straight, and the legs are not
a critical part of the body. But blood flows slowly from the heart and from
the phrenes.* There the veins are slanted, and it is a critical place for insan-
ity and suited for madness.
When these places are filled with blood, shivering sets in with fevers.
They call these “erratic fevers.” When this is the state of affairs, the girl
goes crazy because of the violent inflammation, and she becomes murder-
ous because of the decay and is afraid and fearful because of the darkness.
The girls try to choke themselves because of the pressure on their hearts;
their will, distraught and anguished because of the bad condition of the
blood, forces evil on itself. In some cases the girl says dreadful things: [the
visions] order her to jump up and throw herself into wells and drown, as if
this were good for her and served some useful purpose. When a girl does
not have visions, a desire sets in which compels her to love death as if it

*Editor’s note: The phrenes, or diaphragm, it was believed, was where the work of
mind, thought, and will resided.
36 — The Ancient World
were a form of good. When this person returns to her right mind, women
give to Artemis various offerings, especially the most valuable of women’s
robes, following the orders of oracles, but they are deceived. The fact is that
the disorder is cured when nothing impedes the downward flow of blood.
My prescription is that when virgins experience this trouble, they should
cohabit with a man as quickly as possible. If they become pregnant, they
will be cured. If they don’t do this, either they will succumb at the onset of
puberty or a little later, unless they catch another disease. Among married
women, those who are sterile are more likely to suffer what I have
described.

From Mary R. Lefkowitz and Maureen B. Fant, eds., Women’s Life in Greece and
Rome: A Source Book in Translation, 3rd ed. (Baltimore: Johns Hopkins University
Press, 2005), 237–240, 242–243. ©2005 Mary R. Lefkowitz and Maureen B. Fant.
Reprinted with permission of the Johns Hopkins University Press and by permis-
sion of Gerald Duckworth & Co. Ltd.

The Bible, Mark 5

(ca. 65–75 c.e.)

Of the four Gospels chronicling the life and teachings of Jesus of

Nazareth, Mark’s is considered to be the oldest. Christianity has
historically had a close connection to disease and cure. Like their
Jewish, Greek, and Roman predecessors and contemporaries, early
and medieval Christians believed that sacred power was something
that could be shared by both prophets and madmen alike. Moreover,
Jesus’ fame spread quickly due, in part, to stories of his alleged abil-
ity to cure a host of ailments. The story of Jesus’ encounter with
the Gerasene demoniac is among the most famous in the gospels. A
tenth-century depiction of this scene can be found on the front
cover of our volume.*

*Editor’s note: Thanks to the late Bill Petersen for his suggestions and advice.
 The Bible, Mark 5 — 37
Mark 5

1 They came to the other side of the sea, to the country of the
Ger’asenes.
2 And when he had come out of the boat, there met him out of the
tombs a man with an unclean spirit,
3 who lived among the tombs; and no one could bind him any more,
even with a chain;
4 for he had often been bound with fetters and chains, but the chains he
wrenched apart, and the fetters he broke in pieces; and no one had the
strength to subdue him.
5 Night and day among the tombs and on the mountains he was always
crying out, and bruising himself with stones.
6 And when he saw Jesus from afar, he ran and worshiped him;
7 and crying out with a loud voice, he said, “What have you to do with
me, Jesus, Son of the Most High God? I adjure you by God, do not tor-
ment me.”
8 For he had said to him, “Come out of the man, you unclean spirit!”
9 And Jesus asked him, “What is your name?” He replied, “My name is
Legion; for we are many.”
10 And he begged him eagerly not to send them out of the country.
11 Now a great herd of swine was feeding there on the hillside;
12 and they begged him, “Send us to the swine, let us enter them.”
13 So he gave them leave. And the unclean spirits came out, and entered
the swine; and the herd, numbering about two thousand, rushed down
the steep bank into the sea, and were drowned in the sea.
14 The herdsmen fled, and told it in the city and in the country. And
people came to see what it was that had happened.
15 And they came to Jesus, and saw the demoniac sitting there, clothed
and in his right mind, the man who had had the legion; and they were
afraid.
16 And those who had seen it told what had happened to the demoniac
and to the swine.
17 And they began to beg Jesus to depart from their neighborhood.
18 And as he was getting into the boat, the man who had been possessed
with demons begged him that he might be with him.
19 But he refused, and said to him, “Go home to your friends, and tell
38 — The Ancient World
them how much the Lord has done for you, and how he has had mercy
on you.”
20 And he went away and began to proclaim in the Decap’olis how much
Jesus had done for him; and all men marveled.
21 And when Jesus had crossed again in the boat to the other side, a great
crowd gathered about him; and he was beside the sea.
22 Then came one of the rulers of the synagogue, Ja’irus by name; and
seeing him, he fell at his feet,
23 and besought him, saying, “My little daughter is at the point of death.
Come and lay your hands on her, so that she may be made well, and live.”
24 And he went with him. And a great crowd followed him and thronged
about him.
25 And there was a woman who had had a flow of blood for twelve years,
26 and who had suffered much under many physicians, and had spent all
that she had, and was no better but rather grew worse.
27 She had heard the reports about Jesus, and came up behind him in the
crowd and touched his garment.
28 For she said, “If I touch even his garments, I shall be made well.”
29 And immediately the hemorrhage ceased; and she felt in her body that
she was healed of her disease.
30 And Jesus, perceiving in himself that power had gone forth from him,
immediately turned about in the crowd, and said, “Who touched my
garments?”
31 And his disciples said to him, “You see the crowd pressing around you,
and yet you say, ‘Who touched me?’”
32 And he looked around to see who had done it.
33 But the woman, knowing what had been done to her, came in fear and
trembling and fell down before him, and told him the whole truth.
34 And he said to her, “Daughter, your faith has made you well; go in
peace, and be healed of your disease.”
35 While he was still speaking, there came from the ruler’s house some
who said, “Your daughter is dead. Why trouble the Teacher any fur-
ther?”
36 But ignoring what they said, Jesus said to the ruler of the synagogue,
“Do not fear, only believe.”
37 And he allowed no one to follow him except Peter and James and John
the brother of James.
 Soranus, “Madness or Insanity” — 39
38 When they came to the house of the ruler of the synagogue, he saw a
tumult, and people weeping and wailing loudly.
39 And when he had entered, he said to them, “Why do you make a
tumult and weep? The child is not dead but sleeping.”
40 And they laughed at him. But he put them all outside, and took the
child’s father and mother and those who were with him, and went in
where the child was.
41 Taking her by the hand he said to her, “Tal’itha cu’mi,” which means,
“Little girl, I say to you, arise.”
42 And immediately the girl got up and walked (she was twelve years of
age), and they were immediately overcome with amazement.
43 And he strictly charged them that no one should know this, and told
them to give her something to eat.

From The Common Bible: Revised Standard Version, http:/quod.lib.umich.edu/rlrsv,

copyright 1973 by the Division of Christian Education of the National Council of
the Churches of Christ in the United States of America. Used by permission. All
rights reserved.

Soranus of Ephesus
(ca. second century c.e.)

“Madness or Insanity (Greek Mania)”

Soranus of Ephesus studied medicine in Alexandria and practiced

in Rome during the reigns of the emperors Trajan and Hadrian.
Particularly famous for his treatise on gynecology, he was the
author of many works, and, along with Hippocrates and Galen,
his teachings influenced Western medicine well into the Middle
Ages. Soranus was a proponent of a school of medicine known as
Methodism, which tended to see the body as composed of mov-
ing atoms—as opposed to flowing humors, as the Hippocratic
school viewed it—and held that abnormalities in the movements
40 — The Ancient World
of these atoms caused disease. The excerpt here comes from a
treatise titled On Chronic Diseases. The original text has been lost,
but a reliable Latin translation by the physician Caelius Aure-
lianus (ca. early fifth century C.E.) provides us with valuable
insight into not only the beside manner of the Methodist doctor,
but also experiences and understandings of madness in the Roman
Empire.

Madness or Insanity (Greek Mania)

In the Phaedrus, Plato declares that there are two kinds of mania, one involv-
ing a mental strain that arises from a bodily cause of origin, the other divine
or inspired, with Apollo as the source of the inspiration. This latter kind,
he says, is now called “divination,” but in early times was called “madness”;
that is, the Greeks now call it “prophetic inspiration” (mantice), though in
remote antiquity it was called “mania.” Plato goes on to say that another
kind of divine mania is sent by Father Bacchus, that still another, called
“erotic inspiration,” is sent by the god of love, and that a fourth kind comes
from the Muses and is called “protreptic inspiration” because it seems to
inspire men to song. The Stoics also say that madness is of two kinds, but
they hold that one kind consists in lack of wisdom, so that they can con-
sider every imprudent person mad; the other kind, they say, involves a loss
of reason and a concomitant bodily affection. The school of Empedocles
holds that one form of madness consists in a purification of the soul, and
the other in an impairment of the reason resulting from a bodily disease or
indisposition.
It is this latter form of madness that we shall now consider. The Greeks
call it mania because it produces great mental anguish (Greek ania); or else
because there is excessive relaxing of the soul or mind, the Greek word for
“relaxed” or “loose” being manos; or because the disease defiles the patient,
the Greek word “to defile” being lymaenin; or because it makes the patient
desirous of being alone and in solitude, the Greek word “to be bereft” and
“to seek solitude” being monusthae; or because the disease holds the body
tenaciously and is not easily shaken off, the Greek word for “persistence”
being monia; or because it makes the patient hard and enduring (Greek
hypomeneticos).
 Soranus, “Madness or Insanity” — 41
Mania is an impairment of reason; it is chronic and without fever and
in these respects may be distinguished from phrenitis. For mania is not an
acute disease, nor is it observed to occur with fever; or, if fever is present in
case of mania, the case may be distinguished from phrenitis by considera-
tions of time, for in mania the madness precedes any supervening fever and
the patient does not have a small pulse. In phrenitis, however, the fever
always precedes the madness, and the patient has a small pulse.
Mania occurs more frequently in young and middle-aged men, rarely
in old men, and most infrequently in children and women. Sometimes it
strikes suddenly, at other times it takes hold gradually. Sometimes it arises
from hidden causes, at other times from observable causes, such as expo-
sure to intense heat, the taking of severe cold, indigestion, frequent and
uncontrolled drunkenness (Greek craepale), continual sleeplessness,
excesses of venery, anger, grief, anxiety, or superstitious fear, a shock or
blow, intense straining of the sense and the mind in study, business, or
other ambitious pursuits, the drinking of drugs, especially of those
intended to excite love (Greek philtropota), the removal of long-standing
hemorrhoids or varices, and, finally, the suppression of the menses in
women.
Before the disease emerges, those who are not attacked suddenly by it
have the same symptoms as persons on the verge of epilepsy or of apoplexy.
These signs may be found, then, in what has already been said. But some
seek to distinguish the antecedent signs of these diseases by listing specific
signs for each of them in addition to the general signs common to all. Thus
deep sleep, they say, is indicative of the coming of epilepsy; light and short
sleep, on the other hand, of mania. So, too, they take it as an indication that
mania is imminent when a person in a state of anger suffers congestion of
the head and believes that he has gone mad or, again, when such a person
is overcome by speechlessness resulting from groundless fear. Other such
signs, in their opinion, are unhappiness, mental anxiety, tossing in sleep,
immoderate appetite, frequent blinking of the eyes, palpitation of the heart,
sleep marked by great fear and turmoil, abdominal distention, frequent
passing of wind through the anus, and a small, rapid, hard pulse. On the
other hand, they say that persons on the verge of epilepsy have a large, rare,
and soft pulse. Now these same writers tell us to study the nature of these
diseases as they first come to the body, on the theory that they often attack
the body by a kind of external contact. But all these methods fail, in our
42 — The Ancient World
opinion, to provide an accurate and definite means of distinguishing which
of the aforesaid diseases is imminent in a given case. . . .
Now when the disease of mania emerges into the open, there is impair-
ment of reason unaccompanied by fever; this impairment of reason in some
cases is severe, in others mild; it differs in various cases in its outward form
and appearance, though its nature and character are the same. For, when
mania lays hold of the mind, it manifests itself now in anger, now in mer-
riment, now in sadness or futility, and now, as some related, in an over-
powering fear of things which are quite harmless. Thus the patient will be
afraid of caves or will be obsessed by the fear of falling into a ditch or will
dread other things which may for some reason inspire fear.
The ancients also associated madness with a kind of prophetic power.
And Demetrius calls mania a strain imposed on the mind for a brief period,
saying that some persons in a sudden moment of confusion are so terror-
stricken that they lose their memory of the past. In fact, Apollonius tells us
that when the philologist Artemidorus was lying on the sand he was fright-
ened by the ponderous approach of a crocodile; his mind was so affected by
the sudden sight of the reptile’s motion that he imagined that his left leg
and hand had been eaten by the animal, and he lost his memory even of lit-
erature. Apollonius says that melancholy should be considered a form of
mania, but we distinguish melancholy from mania. And mania or madness
is sometimes continuous and other times relieved by intervals of remission.
Thus the patient sometimes does not remember his tasks, sometimes is
unaware of his own forgetfulness, sometimes suffers impairment of all the
senses, and sometimes is affected by various other types of aberration.
Thus one victim of madness fancied himself a sparrow, another a cock,
another an earthen vessel, another a brick, another a god, another an ora-
tor, another a tragic actor, another a comic actor, another a stalk of grain
and asserted that he occupied the center of the universe, and another cried
like a baby and begged to be carried in the arms. In most cases of mania, at
the time of the actual attack, the eyes become bloodshot and intent. There
is also continual wakefulness, the veins are distended, cheeks flushed, and
body hard and abnormally strong.
In this disease the whole system of nerves and sinews is affected, as we
may gather from the symptoms. But the head is especially affected; and, in
fact, most of the discomfort preceding the attack is in the head, the patient
being affected by a feeling of pain and heaviness there. Also the senses are
 Soranus, “Madness or Insanity” — 43
individually affected, and these are, as we know, centered in the head.
Mania is a major disease; it is chronic and consists of attacks alternating
with periods of remission; it involves a state of stricture. . . . Thus, in the
interval of remission the patient feels fatigued. Our conclusion is further
confirmed by the symptoms that precede the loss of reason, e.g., a feeling
of heaviness in the head, pain in the spine and shoulder blades, sluggish-
ness in the movements of the limbs, and abdominal distention. Thus those
who imagine that the disease is chiefly an affection of the soul and only sec-
ondarily of the body are mistaken. For no philosopher has ever set forth a
successful treatment for this disease; moreover, before the mind is affected,
the body itself shows visible symptoms. This concludes the Methodist
account of the recognition or diagnosis of the disease.
As for the treatment, we hold that measures should be taken similar to
those employed in epilepsy. Thus, to begin with, have the patient lie in a
moderately light and warm room. The room should be perfectly quiet,
unadorned by paintings, not lighted by low windows, and on the ground
floor rather than on the upper stories, for victims of mania have often
jumped out of windows. And the bed should be firmly fastened down. It
should face away from the entrance to the room so that the patient will not
see those who enter. In this way the danger of exciting or aggravating his
madness by letting him see many different faces will be avoided. And the
bedclothes should be soft.
Rub the patient’s limbs and hold them gently. If any part of the body
is shaken by a throbbing movement, relieve it with warmth, applying soft
scoured wool to the head, too, the neck and circularly to the chest. Also
employ a fomentation of warm olive oil, sometimes adding, for its sooth-
ing properties, fenugreek water (obtained from a decoction of fenugreek;
but see that it is not thick), or else an infusion of marsh mallow or
flaxseed. Then wash the patient’s mouth and have him take a drink of
warm water.
Do not permit many people, especially strangers, to enter the room.
And instruct servants to correct the patient’s aberrations while giving them
a sympathetic hearing. That is, have the servants, on the one hand, avoid
the mistake of agreeing with everything the patient says, corroborating all
his fantasies, and thus increasing his mania; and, on the other hand, have
them avoid the mistake of objecting to everything he says and thus aggra-
vating the severity of the attack. . . .
44 — The Ancient World
If the patient is excited when he sees people, bind him without doing
any injury. First cover his limbs with wool and then fasten with a bandage.
Now if there is a person whom the patient has customarily feared or
respected, he should not be brought into the sickroom repeatedly. For this
frequent repetition gives rise to a lack of regard. But when circumstances
require it, as when the patient does not submit to the application of a rem-
edy, this person should then be brought in to overcome the patient’s stub-
bornness, by inspiring fear or respect. And if you observe that the light is
upsetting his mind, shade his eyes but let the rest of his body be touched
by the light.
Do not give the patient food until the end of the first three-day period;
and if his strength permits and the disease requires it, perform venesection
before the end of the three-day period. If there is any reason why an ade-
quate withdrawal of blood cannot be made, take the amount required in
several operations. But if there is no reason for doing otherwise, perform
the venesection at the end of the three-day period.
After venesection anoint the patient, foment his face, and give him a
small quantity of light and digestible food, e.g., bread in warm water, spelt
groats mixed with honey which has been boiled down moderately, and
some other gruel-like or soft food. Thereafter, feed the patient on alternate
days, if his strength permits, until the disease declines. And if the case
requires it, purge with a simple clyster. Again, relax the precordial region
with poultices as an aid to digestion. The purpose is to prevent any state of
constriction from causing the pent-up gases to pass to the head. Attention
must also be paid to the type of mental aberration involved, for its symp-
toms will have to be relieved by properly reasonable countermeasures.
Thus they [the servants] will soothe a patient with cheerfulness, telling
him something to relax his mind.
And when the highest stage of the attack is reached, cut the patient’s
hair and shave his head; then apply cupping with scarification, beginning
with the precordia, and then passing to the region between the shoulder
blades (Greek metaphrenon). For in these cases the upper parts of the body
are apt to be sympathetically affected. Then apply cupping in conjunction
with scarification to the occiput, the top of the head, and the temples. And
if the face is particularly affected, relax the whole body using leeches, which
we call hirudines. Then use poultices of bread and other substances with
relaxing properties, followed by an application of heat with sponges. And if
 Soranus, “Madness or Insanity” — 45
the disease persists, keep using the same remedies a second or even a third
time. If the patient is wakeful, prescribe passive exercise, first in a hammock
and then in a sedan chair. The rapid dripping of water may be employed to
induce sleep, for under the influence of its sound patients often fall asleep.
And heat should then be applied to the eyes with warm sponges, and the
stiffness of the lids relaxed; for the beneficial effects of this treatment will
pass through the eyes to the membranes of the brain.
When the disease declines and the patient’s wakefulness and mental
aberration are very much reduced, give him varied food of the middle class.
. . . And then prescribe passive exercise, first in a sedan chair and then in a
cart drawn by hand. When the patient’s body has gained strength, pre-
scribe walking and also vocal exercise, as required by the case. Thus have
the patient read aloud even from texts that are marred by false statements.
In this way he will exercise his mind more thoroughly. And for the same
reason he should also be kept busy answering questions. This will enable
us both to detect malingering and to obtain the information we require.
Then let him relax, giving him reading that is easy to understand; injury
due to overexertion will thus be avoided. For if these mental exercises over-
tax the patient’s strength, they are no less harmful than passive exercise car-
ried to excess.
And so after the reading let him see a stage performance. A mime is
suitable if the patient’s madness has not manifested itself in dejection; on
the other hand, a composition depicting sadness or tragic error is suitable
in cases of madness which involve childish playfulness. For the particular
characteristic of a case of mental disturbance must be corrected by empha-
sizing the opposite quality, so that the mental condition, too, may attain the
balanced state of health. And as the treatment proceeds, have the patient
deliver discourses or speeches, as far as his strength permits. And in this
case the speeches should all be arranged in the same way, the introduction
to be delivered with a gentle voice, the narrative portions and proof more
loudly and intensely, and the conclusion, again, in a subdued and kindly
manner. This is in accordance with the precepts of those who have written
on vocal exercise (Greek anaphonesis). An audience should be present, con-
sisting of persons familiar to the patient; by according the speech favorable
attention and praise, they will help relax the speaker’s mind. And, in fact,
any pleasant bodily exercise promotes the general health. Soon after the dis-
course or speech, the patient should be taken and gently anointed; he
46 — The Ancient World
should then take a light walk for exercise.
Now if he is unacquainted with literature, give him problems appropri-
ate to his particular craft, e.g., agricultural problems if he is a farmer, prob-
lems in navigation if he is a pilot. And if he is without any skill whatever,
give him questions on commonplace matters, or let him play checkers.
Such a game can exercise his mind, particularly if he plays with a more expe-
rienced opponent. . . .
Serve the patient varied food, as we indicated above in discussing
epilepsy. Do not give him wine at first, but add some fruit to his diet to test
the body. Afterward give him a small quantity of thin, mild wine at the time
of eating. At first, the wine should be given at intervals of five days, and, as
times goes on, at intervals of four, three, two, and then on alternate days;
finally, it maybe be given every day. But water should be drunk in the inter-
vals, the amount decreasing in proportion as the allotment of wine becomes
more liberal.
Then, if the patient shows no new symptoms and has accustomed him-
self to the various parts of his regimen, change of climate should be pre-
scribed. And if he is willing to hear discussion of philosophers, he should
be afforded the opportunity. For by their words philosophers help to ban-
ish fear, sorrow, and wrath, and in so doing make no small contribution to
the health of the body.
But if the disease persists and becomes chronic, being marked by
attacks alternating with intervals of remission, relieve the attacks using the
same remedies as those prescribed above for the initial attack of mania. But
in the intervals of remission, prescribe, first, the restorative series of treat-
ments including various types of passive exercise, vocal exercise arranged
under supervision of a musician, walking, passive exercise, varied food, and
the like. Follow this series with the metasyncritic cycle, as we have
described it above.

From Soranus of Ephesus, “Madness or Insanity (Greek Mania)” in Caelius Aure-

lianus, On Acute Diseases and on Chronic Diseases, edited and translated by I. E.
Drabkin (Chicago: University of Chicago Press, 1950), 535–559. Copyright 1950
by the University of Chicago. All rights reserved. Published 1950. Composed and
printed by The University of Chicago Press, Chicago, Illinois, U.S.A.
 Medieval and Early
Modern Europe

Sara–biyu
– n Ibn Ibra–hi–m, .
“Three Cases of Melancholia
by Rufus of Ephesus”
(ca. 873 c.e.)

Rufus of Ephesus (first century C.E.) was an ancient physician who

authored an influential two-volume work on the causes, symptoms,
and treatment of melancholia. The work is lost and is now known
only from citations in other works. But it was disseminated in Ara-
bic translation throughout the Middle Ages. Rufus’s method can be

textbook of Sara–biyu .
seen in the cases that are reproduced in the ninth-century Arabic
– n Ibn Ibra–hi–m. Among those who relied heav-
ily on his understanding of the affliction was the famous Greek
physician Galen. There is good evidence to suggest it was Rufus
who was responsible for locating the seat of melancholia in the
brain.

I knew another man, and he had pain between the ribs every year in the
spring, without fever or inflammation but with stinging and pricking. Heat
did not appear in the [affected] part. For this condition he used to have his
blood let every year and take a purgative. He suffered from the illness
between the autumnal equinox and the height of the heat in the spring,

47
48 — Medieval and Early Modern Europe
when the disease would subside on account of the bleeding and the use of
purgatives. When he thought that he did not benefit from the two [treat-
ments], he gave them up. The pain returned for about a month and rose to
his chest. Then, he had some blood let and took a purgative. The pain did
not subside but extended to the side of his face; he felt it only on one side
[of his face], and it affected his jaw for a while. When I feared that it might
pass to his eye and brain and that it might kill him, I asked him to have his
blood let and to take the purgative three times. Then, I cauterized his ribs
where there was pain. The pain subsided completely. He had nothing to
complain about for four days. On the fifth day he began to see phantoms
before his eyes. I did not risk evacuation because his body was weakened. I
prescribed for him a moist diet, so that the evacuation could take place eas-
ily if I had to resort to it. The phantoms remained for two more days. On
the third day the symptoms of melancholia appeared, and all hope was
given up for him, but I was sure that I had stopped the matter. These symp-
toms did not frighten me. I fed him with barley juice, rock fish, and bean
soup for about thirty days. Because everything moistened his body, the
symptoms of melancholia receded until he was completely recovered. The
symptoms of melancholia were sadness and fear of death. Therefore, I pre-
scribed for him entertainment and pleasure. He was over it in eighty days.
The physicians were baffled by his recovery—how the matter was inclined
toward the noble part of the body after being evacuated and, then, how the
illness left him without any [further] evacuation. I showed them that it was
a surplus of black bile that was blocked in some of his arteries. It had
changed and had corrupted the blood in the arteries little by little. After we
evacuated it, the quality persisted, but we had eliminated its source, so that
it decreased gradually. When it reached the brain it had become quite weak.
It found in the brain, however, a dry moist humor from the sadness and
insomnia that the patient had suffered. Because of this, the rest became like
dough; it was changed into black bile and caused melancholia. When we
moistened his diet and removed his sadness, the damage ceased.
I know another man with whom melancholia began from the burning
of the blood. He was a man of leisure. The anxiety and sorrow that he suf-
fered were not great, for a little joy was mixed with them. The reason [for
the melancholia] was his constant preoccupation with mathematical sci-
ences. He was also a courtier. Because of these things, bilious matter col-
lected in him at the age that it is customarily created, that is in the period
 .
Ibn Ibra–hi–m, “Three Cases of Melancholia” — 49
of decline. Besides, he had a fiery temperament in his youth, so that as he
advanced in age, black bile collected in him. He had fits mostly at night
because of his insomnia and in the morning. When he slept at daybreak,
he saw evil phantoms in his sleep because of lethargy (suba–t) caused by the
insomnia. He was treated by an inexperienced physician who evacuated
him many times with strong emetics. He neglected the balance of his
[patient’s] temperament. The restoration of the temperament in diseases
like these is the best treatment because the badness of the temperament
produces such a humour as this one. The creation of the humour is not
stopped except by the restitution of the temperament. When his tempera-
ment was agitated by these treatments, the burning in his body increased.
His condition led to madness ( junu–n); he continued not to eat or drink
until he died.
Another man who was 21 years old was rescued from drowning. He
suffered from melancholia on account of the fear caused by it. A physician
treated him with methods like the ones that have been described, i.e.
repeated evacuation by means of emetics. In the end, [the doctor] evacu-
ated him with black hellebore, but he didn’t know any better. Then,
another physician treated him by moistening, nourishment, and amuse-
ment. The man was rightly guided and recovered. His recovery was really
due to both the doctors because the first physician evacuated the matter
and the second corrected the temperament.

From Michael W. Dols, Majnun: The Madman in Medieval Islamic Society, edited by
Diana E. Immisch (Oxford: Clarendon, 1992), 479–480. By permission of Oxford
University Press.
50 — Medieval and Early Modern Europe

.
Ibn Si–na– [Avicenna]
(ca. 980–1037)

“Lovesickness”
(first Latin translation, twelfth century)

.
The Persian philosopher and physician Ibn Si–na–—known in the
Latin-speaking world as Avicenna—was one of the most esteemed
thinkers of the medieval period. His renowned medical text, Al-
Qa–nun– (The Canon), was an attempt to harmonize Aristotelian phi-
losophy with Galenic medicine, and it remained an essential medical

.
text throughout the Middle East and Europe for centuries.
Among the topics Ibn Si–na– discussed was the ailment known as
“lovesickness.” A malady that can be traced back to ancient times,
lovesickness was viewed as a potentially lethal affliction (Thomas,
Archbishop of York, is purported to have died of it in 1114). The
existence and disappearance of the diagnosis of lovesickness raises
some interesting questions. As one historian has put it: “Was
lovesickness real, simply to evolve into the erotomania of the Vic-
torians? Is it the cause of stalking in our times? Or maybe even the
source of fidelity and genuine sacrifice?”*

.
This is a delusionary (waswa–si–) illness, which is similar to melancholia.
The individual brought it about in his own psyche (nafs) by his obsession
that overwhelmed his discretion about appearances and character. It helped
him to attain his desire, or it did not. The characteristics of the illness are
hollowness of the eyes and their dryness, the lack of moisture except when
weeping, continuous movement of the eyelids, and laughing as if he sees
something pleasant or hears happy news or jokes. His psyche is full of
alienation and withdrawal, so that there is much deep sighing. His condi-
tion changes from exhilaration and laughter to sadness and weeping when
he hears love poetry (ghazal), especially when he remembers the separation

*W. F. Bynum, “Lovesickness,” Lancet 357 (2001): 403.

 .
Ibn Si–na–, “Lovesickness” — 51
and distance from his beloved. All of his bodily parts are moist except the
eyes; besides their hollowness, the eyelids are heavy because of insomnia
and sighing. His behavior is disordered, and his pulse is irregular, like those
who are anxious. His pulse and his condition change at the mention of the
beloved (ma’shu–q) especially and when he meets his beloved suddenly. It is
possible, therefore, to learn the identity of the beloved person if the patient
will not reveal it, and the knowledge of the beloved is the best way of treat-
ing the patient. The way of doing this is to mention many names repeat-
edly while the finger is kept on his pulse, and when it becomes very
irregular and almost stops, you should then repeat the procedure. I have
tried this method several times, and I have learned the name of the beloved.
Then, in a similar manner, the lanes, houses, professions, crafts, families,
and countries are mentioned, combining each of them with the name of
the beloved, while you keep your hand on the pulse. When it changes at the
mention of one thing several times, you will know from this method all
the particulars of the beloved—the name, appearance, and occupation. We
have tried this procedure and have discovered the useful information.
If you cannot find any cure except to unite the two in a manner that is
.
permitted by religion and the law (shari–’a), do it. We have seen cases where
health and strength were fully regained and the flesh restored. [In one
instance] wasting had progressed and overcome a man; he had suffered
severe chronic illness and prolonged fevers as the result of his bodily weak-
ness that was caused by the strength of ‘ishq. When he experienced union
with his beloved, recovery occurred in a very short time. We were aston-
ished at it and realized the subordination of the constitution (tabi–’a) to .
mental delusions (awha–m).
Treatment: You should consider whether his condition is attributable
to the burning of the humor by the signs that you know; if so, you should
evacuate. Then, concern yourself with moisturizing their bodies, lulling
them to sleep, and nourishing them with good foods, and help them to pre-
serve their equanimity in disputes, activities, and quarrels—matters that
generally preoccupy men’s minds. If that were done, it sometimes makes
them forget what caused them to be seriously ill. Or you can deceive them
by joining the lover with someone other than the beloved, whom the law
permits; then, their thinking about the second person should be cut off
before it grows stronger and after they have forgotten about the first. When
the lover is a reasonable person, he can be given sincere advice and warn-
52 — Medieval and Early Modern Europe
ing, as well as being ridiculed and rebuked. The image that he has within
himself is nothing but a delusion and a kind of madness. Medical advice
about it, as in this chapter, is useful, as well as the power of old women over
it. For the women make the beloved hateful to him; they report the
beloved’s unclean conditions, and they tell him repulsive things about the
one he loves, and they convey the beloved’s considerable loathing for him.
All of this is something that is very calming [for the lovesick]. If it were so,
it may bring about other [benefits]. Among the useful things in this situa-
tion is for these old women to mimic the appearance of the beloved with
ugly imitations and to present parts of the body in a shameful parody. They
continue to do that and to speak about the beloved in great detail because
it is their job. They are more proficient at it than men, except for the effem-
inate men whose skill is not inferior to that of the old women. They are also
able to transfer gradually the lust (hawa–) of the lover to someone other
than the beloved. Then, they stop their actions before the second lust gains
ground. Among the recommended activities are also the buying of slave-
girls and the increase of sexual intercourse, acquiring new partners and tak-
ing pleasure in them. Some people are consoled with entertainment and
recitation, while for others it only increases their infatuation; it is possible
to discover which is which. Or hunting, different kinds of games, renewed
patronage, and the company of important people—all of these ways bring
consolation. Sometimes it is necessary that you arrange these things for
those who suffer from melancholia, mania, and lycanthropy (qutrub) and
that they are evacuated with strong laxatives (aya–rja–t) and moistened with
what has been said [in this section] on moisturizers. Therefore, if men are
changed in their character and in the appearance of their bodies to resem-
ble this [condition], you must concern yourself with moisturizing their
bodies.

From Michael W. Dols, Majnun: The Madman in Medieval Islamic Society, edited by
Diana E. Immisch (Oxford: Clarendon, 1992), 484–485. By permission of Oxford
University Press.
 Julian of Norwich, Revelations of Divine Love — 53

Julian of Norwich
(1342–ca. 1416)

Revelations of Divine Love

(ca. 1390s)

Julian was a Christian mystic and anchoress in the English town of

Norwich. As she later recounted in Revelations of Divine Love, while
gravely ill in 1373, she began to have a series of visions of Jesus.
These “shewings,” as she referred to them, convinced her to dedi-
cate herself to living a life aimed at spiritual perfection. To do this,
she subsequently shut herself up in an isolated cell attached to what
is now known as St. Julian’s Church.
Experiences like Julian’s and those of her contemporary Margery
Kempe raise challenging questions about how societies and individ-
uals differentiate between legitimate and illegitimate spiritual expe-
riences. Does this constitute a case of “lovesickness” or does it,
rather, simply represent an example of profound devotion? Like
their ancient counterparts, observers during the second millennium
C.E. frequently considered unusual or unconventional expressions
of religious faith to be signs of insanity. This is not meant to say
that Julian was, in fact, mad. Rather, it is important to consider
Julian’s case in relation to those of, for instance, Saul and Jesus in
the ancient world or Daniel Paul Schreber or Thea H. (discussed
later in this volume) in the modern period, in order to understand
what makes a community consider an experience a case of religious
transcendence or evidence of madness.

Chapter II

A simple creature unlettered.—

Which creature afore desired
three gifts of God

these Revelations were shewed to a simple creature unlettered, the year of

our Lord 1373, the Thirteenth day of May. Which creature [had] afore
54 — Medieval and Early Modern Europe
desired three gifts of God. The First was mind of His Passion; the Second
was bodily sickness in youth, at thirty years of age; the Third was to have
of God’s gift three wounds.
As to the First, methought I had some feeling in the Passion of Christ,
but yet I desired more by the grace of God. Methought I would have been
that time with Mary Magdalene, and with other that were Christ’s lovers,
and therefore I desired a bodily sight wherein I might have more knowledge
of the bodily pains of our Saviour and of the compassion of our Lady and of
all His true lovers that saw, that time, His pains. For I would be one of them
and suffer with Him. Other sight nor shewing of God desired I never none,
till the soul were disparted from the body. The cause of this petition was
that after the shewing I should have the more true mind in the Passion of
Christ.
The Second came to my mind with contrition; [I] freely desiring that
sickness [to be] so hard as to death, that I might in that sickness receive
all my rites of Holy Church, myself thinking that I should die, and that
all creatures might suppose the same that saw me: for I would have no
manner of comfort of earthly life. In this sickness I desired to have all
manner of pains bodily and ghostly that I should have if I should die,
(with all the dreads and tempests of the fiends) except the outpassing of
the soul. And this I meant for [that] I would be purged, by the mercy of
God, and afterward live more to the worship of God because of that sick-
ness. And that for the more furthering in my death: for I desired to be
soon with my God.
These two desires of the Passion and the sickness I desired with a con-
dition, saying thus: Lord, Thou knowest what I would,—if it be Thy will that
I have it—; and if it be not Thy will, good Lord, be not displeased: for I will
nought but as Thou wilt.
For the Third [petition], by the grace of God and teaching of Holy
Church I conceived a mighty desire to receive three wounds in my life: that
is to say, the wound of very contrition, the wound of kind compassion, and
the wound of steadfast longing toward God. And all this last petition I
asked without any condition.
These two desires aforesaid passed from my mind, but the third
dwelled with me continually.
 Julian of Norwich, Revelations of Divine Love — 55
Chapter III

I desired to suffer with Him

and when I was thirty years old and a half, God sent me a bodily sickness,
in which I lay three days and three nights; and on the fourth night I took
all my rites of Holy Church, and weened not thought of, designed to have
lived till day. And after this I languored forth two days and two nights, and
on the third night I weened oftentimes to have passed; and so weened they
that were with me.
And being in youth as yet, I thought it great sorrow to die;—but for
nothing that was in earth that meliked to live for, nor for no pain that I had
fear of: for I trusted in God of His mercy. But it was to have lived that I
might have loved God better, and longer time, that I might have the more
knowing and loving of God in bliss of Heaven. For methought all the time
that I had lived here so little and so short in regard of that endless bliss,—
I thought [it was as] nothing. Wherefore I thought: Good Lord, may my liv-
ing no longer be to Thy worship! And I understood by my reason and by my
feeling of my pains that I should die; and I assented fully with all the will of
my heart to be at God’s will.
Thus I dured till day, and by then my body was dead from the middle
downwards, as to my feeling. Then was I minded to be set upright, back-
ward leaning, with help,—for to have more freedom of my heart to be at
God’s will, and thinking on God while my life would last.
My Curate was sent for to be at my ending, and by that time when he
came I had set my eyes, and might not speak. He set the Cross before my
face and said: I have brought thee the Image of thy Master and Saviour: look
thereupon and comfort thee therewith.
Methought I was well [as it was], for my eyes were set uprightward
unto Heaven, where I trusted to come by the mercy of God; but neverthe-
less I assented to set my eyes on the face of the Crucifix, if I might; and so
I did. For methought I might longer dure to look evenforth than right up.
After this my sight began to fail, and it was all dark about me in the
chamber, as if it had been night, save in the Image of the Cross whereon I
beheld a common light; and I wist not how. All that was away from the
Cross was of horror to me, as if it had been greatly occupied by the fiends.
After this the upper part of my body began to die, so far forth that
scarcely I had any feeling;—with shortness of breath.
56 — Medieval and Early Modern Europe
And then I weened in sooth to have passed. And in this [moment] sud-
denly all my pain was taken from me, and I was as whole (and specially in
the upper part of my body) as ever I was afore.
I marvelled at this sudden change; for methought it was a privy work-
ing of God, and not of nature. And yet by the feeling of this ease I trusted
never the more to live; nor was the feeling of this ease any full ease unto
me: for methought I had liefer have been delivered from this world.
Then came suddenly to my mind that I should desire the second
wound of our Lord’s gracious gift: that my body might be fulfilled with
mind and feeling of His blessed Passion. For I would that His pains were
my pains, with compassion and afterward longing to God. But in this I
desired never bodily sight nor shewing of God, but compassion such as a
kind soul might have with our Lord Jesus, that for love would be a mortal
man: and therefore I desired to suffer with Him.

The First Revelation

Chapter IV

I saw . . . as it were in the time of His

Passion . . . And in the same Shewing
suddenly the Trinity filled my heart
with utmost joy

in this [moment] suddenly I saw the red blood trickle down from under the
Garland hot and freshly and right plenteously, as it were in the time of His
Passion when the Garland of thorns was pressed on His blessed head who
was both God and Man, the same that suffered thus for me. I conceived
truly and mightily that it was Himself shewed it me, without any mean.
And in the same Shewing suddenly the Trinity fulfilled my heart most
of joy. And so I understood it shall be in heaven without end to all that shall
come there. For the Trinity is God: God is the Trinity; the Trinity is our
Maker and Keeper, the Trinity is our everlasting love and everlasting joy
and bliss, by our Lord Jesus Christ. And this was shewed in the First
[Shewing] and in all: for where Jesus appeareth, the blessed Trinity is
understood, as to my sight.
And I said: Benedicite Domine! This I said for reverence in my meaning,
with mighty voice; and full greatly was astonied for wonder and marvel that
 Julian of Norwich, Revelations of Divine Love — 57
I had, that He that is so reverend and dreadful will be so homely with a sin-
ful creature living in wretched flesh.
This [Shewing] I took for the time of my temptation,—for methought
by the sufferance of God I should be tempted of fiends ere I died. Through
this sight of the blessed Passion, with the Godhead that I saw in mine
understanding, I knew well that It was strength enough for me, yea, and for
all creatures living, against all the fiends of hell and ghostly temptation.
In this [Shewing] He brought our blessed Lady to my understanding.
I saw her ghostly, in bodily likeness: a simple maid and a meek, young of
age and little waxen above a child, in the stature that she was when she con-
ceived. Also God shewed in part the wisdom and the truth of her soul:
wherein I understood the reverent beholding in which she beheld her God
and Maker, marvelling with great reverence that He would be born of her
that was a simple creature of His making. And this wisdom and truth:
knowing the greatness of her Maker and the littleness of herself that was
made,—caused her to say full meekly to Gabriel: Lo me, God’s handmaid! In
this sight I understood soothly that she is more than all that God made
beneath her in worthiness and grace; for above her is nothing that is made
but the blessed Manhood Of Christ, as to my sight.

Chapter V

God, of Thy Goodness, give me

Thyself;—only in Thee I have all

in this same time our Lord shewed me a spiritual sight of His homely lov-
ing. I saw that He is to us everything that is good and comfortable for us:
He is our clothing that for love wrappeth us, claspeth us, and all encloseth
us for tender love, that He may never leave us; being to us all-thing that is
good, as to mine understanding.
Also in this He shewed me a little thing, the quantity of an hazel-nut,
in the palm of my hand; and it was as round as a ball. I looked thereupon
with eye of my understanding, and thought: What may this be? And it was
answered generally thus: It is all that is made. I marvelled how it might last,
for methought it might suddenly have fallen to naught for little[ness]. And
I was answered in my understanding: It lasteth, and ever shall [last] for that
God loveth it. And so All-thing hath the Being by the love of God.
58 — Medieval and Early Modern Europe
In this Little Thing I saw three properties. The first is that God made
it, the second is that God loveth it, the third, that God keepeth it. But what
is to me verily the Maker, the Keeper, and the Lover,—I cannot tell; for till
I am Substantially oned to Him, I may never have full rest nor very bliss:
that is to say, till I be so fastened to Him, that there is right nought that is
made betwixt my God and me.
It needeth us to have knowing of the littleness of creatures and to hold
as nought all-thing that is made, for to love and have God that is unmade.
For this is the cause why we be not all in ease of heart and soul: that we
seek here rest in those things that are so little, wherein is no rest, and know
not our God that is All-mighty, All-wise, All-good. For He is the Very Rest.
God willeth to be known, and it pleaseth Him that we rest in Him; for all
that is beneath Him sufficeth not us. And this is the cause why that no soul
is rested till it is made nought as to all things that are made. When it is will-
ingly made nought, for love, to have Him that is all, then is it able to receive
spiritual rest.
Also our Lord God shewed that it is full great pleasance to Him that a
helpless soul come to Him simply and plainly and homely. For this is the
natural yearnings of the soul, by the touching of the Holy Ghost (as by the
understanding that I have in this Shewing): God, of Thy Goodness, give me
Thyself: for Thou art enough to me, and I may nothing ask that is less that may
be full worship to Thee; and if I ask anything that is less, ever me wanteth,—but
only in Thee I have all.
And these words are full lovely to the soul, and full near touch they the
will of God and His Goodness. For His Goodness comprehendeth all His
creatures and all His blessed works, and overpasseth without end. For He
is the endlessness, and He hath made us only to Himself, and restored us
by His blessed Passion, and keepeth us in His blessed love; and all this of
His Goodness.

Chapter IX

If I look singularly to myself,

I am right nought

because of the Shewing I am not good but if I love God the better: and in
as much as ye love God the better, it is more to you than to me. I say not
 Julian of Norwich, Revelations of Divine Love — 59
this to them that be wise, for they wot it well; but I say it to you that be
simple, for ease and comfort: for we are all one in comfort. For truly it was
not shewed me that God loved me better than the least soul that is in grace;
for I am certain that there be many that never had Shewing nor sight but of
the common teaching of Holy Church, that love God better than I. For if I
look singularly to myself, I am right nought; but in [the] general [Body] I
am, I hope, in oneness of charity with all mine even-Christians.
For in this oneness standeth the life of all mankind that shall be saved.
For God is all that is good, as to my sight, and God hath made all that is
made, and God loveth all that He hath made: and he that loveth generally
all his even-Christians for God, he loveth all that is. For in mankind that
shall be saved is comprehended all: that is to say, all that is made and the
Maker of all. For in man is God, and God is in all. And I hope by the grace
of God he that beholdeth it thus shall be truly taught and mightily com-
forted, if he needeth comfort.
I speak of them that shall be saved, for in this time God shewed me
none other. But in all things I believe as Holy Church believeth, preacheth,
and teacheth. For the Faith of Holy Church, the which I had aforehand
understood and, as I hope, by the grace of God earnestly kept in use and
custom, stood continually in my sight: [I] willing and meaning never to
receive anything that might be contrary thereunto. And with this intent I
beheld the Shewing with all my diligence: for in all this blessed Shewing I
beheld it as one in God’s meaning.
All this was shewed by three [ways]: that is to say, by bodily sight, and
by word formed in mine understanding, and by spiritual sight. But the spir-
itual sight I cannot nor may not shew it as openly nor as fully as I would.
But I trust in our Lord God Almighty that He shall of His goodness, and
for your love, make you to take it more spiritually and more sweetly than I
can or may tell it.

From Julian of Norwich, Revelations of Divine Love (Grand Rapids: Christian Clas-
sics Ethereal Library, 1901), 2–13.
60 — Medieval and Early Modern Europe

Desiderius Erasmus
(ca. 1466–1536)

The Praise of Folly

(1511)

Erasmus was a Catholic theologian and writer and a key figure in the
sixteenth-century scholarly movement known as humanism. His
insistence that classical Greek and Roman teachings were vital in
the quest for wisdom led him at times to be critical of the Church.
Still, when Martin Luther (1483–1546) began contesting official
doctrine, Erasmus remained steadfastly loyal to the Catholic faith.
Soon after arriving in England in 1509, Erasmus began writing
Moriae Encomium (The Praise of Folly) while staying at the house of
his good friend Thomas More (1478–1535). The text begins satir-
ically, as Folly—in female voice—explains her origins and accom-
plishments. Later on, Erasmus turns his attention to what he
considered to be some of the Church’s failings. In the context of the
history of madness, The Praise of Folly offers a chance to appreciate
the broader cultural connotations of the terms folly and foolishness
(in Latin, stultitia or insania), beyond the medical setting.

Of my name I have informed you, Sirs; what additional epithet to give you
I know not, except you will be content with that of most foolish; for under
what more proper appellation can the goddess Folly greet her devotees? But
since there are few acquainted with my family and original, I will now give
you some account of my extraction.
First then, my father was neither the chaos, nor hell, nor Saturn, nor
Jupiter, nor any of those old, worn out, grandsire gods, but Plutus, the very
same that, maugre Homer, Hesiod, nay, in spite of Jove himself, was the pri-
mary father of the universe; at whose alone beck, for all ages, religion and
civil policy, have been successively undermined and re-established; by
whose powerful influence war, peace, empire, debates, justice, magistracy,
marriage, leagues, compacts, laws, arts, (I have almost run myself out of
 Erasmus, The Praise of Folly — 61
breath, but) in a word, all affairs of church and state, and business of pri-
vate concern, are severally ordered and administered; without whose assis-
tance all the Poets’ gang of deities, nay, I may be so bold as to say the very
majordomos of heaven, would either dwindle into nothing, or at least be
confined to their respective homes without any ceremonies of devotional
address: whoever he combats with as an enemy, nothing can be armour-
proof against his assaults; and whosoever he sides with as a friend, may
grapple at even hand with Jove, and all his bolts. Of such a father I may well
brag; and he begot me, not of his brain, as Jupiter did the hag Pallas, but of
a pretty young nymph, famed for wit no less than beauty: and this feat was
not done amidst the embraces of dull nauseous wedlock, but what gave a
greater gust to the pleasure, it was done at a stolen bout, as we may mod-
estly phrase it. But to prevent your mistaking me, I would have you under-
stand that my father was not that Plutus in Aristophanes, old, dry,
withered, sapless and blind; but the same in his younger and brisker days,
and when his veins were more impregnated, and the heat of his youth
somewhat higher inflamed by a chirping cup of nectar, which for a whet to
his lust he had just before drank very freely of at a merry-meeting of the
gods. And now presuming you may be inquisitive after my birth-place (the
quality of the place we are born in, being now looked upon as a main ingre-
dient of gentility), I was born neither in the floating Delo’s, nor on the
frothy sea, nor in any of these privacies, where too forward mothers are
wont to retire for an undiscovered delivery; but in the fortune islands,
where all things grow without the toil of husbandry, wherein there is no
drudgery, no distempers, no old age, where in the fields grow no daffodils,
mallows, onions, pease, beans, or such kind of trash, but there give equal
divertisement to our sight and smelling, rue, all-heal, bugloss, marjoram,
herb of life, roses, violets, hyacinth, and such like fragrances as perfume the
gardens of Adonis. And being born amongst these delights, I did not, like
other infants, come crying into the world, but perked up, and laughed
immediately in my mother’s face. And there is no reason I should envy Jove
for having a she-goat to his nurse, since I was more creditably suckled by
two jolly nymphs; the name of the first drunkenness, one of Bacchus’s off-
spring, the other ignorance, the daughter of Pan; both which you may here
behold among several others of my train and attendants, whose particular
names, if you would fain know, I will give you in short. This, who goes with
a mincing gait, and holds up her head so high, is Self-Love. She that looks
62 — Medieval and Early Modern Europe
so spruce, and makes such a noise and bustle, is Flattery. That other, which
sits hum-drum, as if she were half asleep, is called Forgetfulness. She that
leans on her elbow, and sometimes yawningly stretches out her arms, is
Laziness. This, that wears a plighted garland of flowers, and smells so per-
fumed, is Pleasure. The other, which appears in so smooth a skin, and pam-
pered-up flesh, is Sensuality. She that stares so wildly, and rolls about her
eyes, is Madness. As to those two gods whom you see playing among the
lasses the name of the one is Intemperance, the other Sound Sleep. By the
help and service of this retinue I bring all things under the verge of my
power, lording it over the greatest kings and potentates.
You have now heard of my descent, my education, and my attendance;
that I may not be taxed as presumptuous in borrowing the title of a goddess,
I come now in the next place to acquaint you what obliging favours I every-
where bestow, and how largely my jurisdiction extends: for if, as one has
ingenuously noted, to be a god is no other than to be a benefactor to
mankind; and if they have been thought deservedly deified who have
invented the use of wine, corn, or any other convenience for the well-being
of mortals, why may not I justly bear the van among the whole troop of gods,
who in all, and toward all, exert an unparalleled bounty and beneficence?
For instance, in the first place, what can be more dear and precious
than life itself? And yet for this are none beholden, save to me alone. For it
is neither the spear of throughly-begotten Pallas, nor the buckler of cloud-
gathering Jove, that multiplies and propagates mankind: but that prime
father of the universe, who at a displeasing nod makes heaven itself to trem-
ble, he (I say) must lay aside his frightful ensigns of majesty, and put away
that grim aspect wherewith he makes the other gods to quake, and, stage
player-like, must lay aside his usual character, if he would do that, the doing
whereof he cannot refrain from, i.e., getting of children. The next place to
the gods is challenged by the Stoicks; but give me one as stoical as ill-nature
can make him, and if I do not prevail on him to part with his beard, that
bush of wisdom, (though no other ornament than what nature in more
ample manner has given to goats,) yet at least he shall lay by his gravity,
smooth up his brow, relinquish his rigid tenets, and in despite of prejudice
become sensible of some passion in wanton sport and dallying. In a word,
this dictator of wisdom shall be glad to take Folly for his diversion, if ever
he would arrive to the honour of a father. And why should I not tell my
story out? To proceed then: is it the head, the face, the breasts, the hands,
 Erasmus, The Praise of Folly — 63
the ears, or other more comely parts, that serve for instruments of genera-
tion? I trow not, but it is that member of our body which is so odd and
uncouth as can scarce be mentioned without a smile. This part, I say, is that
fountain of life, from which originally spring all things in a truer sense than
from the elemental seminary. Add to this, what man would be so silly as to
run his head into the collar of a matrimonial noose, if (as wise men are wont
to do) he had before-hand duly considered the inconveniences of a wedded
life? Or indeed what woman would open her arms to receive the embraces
of a husband, if she did but forecast the pangs of child-birth, and the plague
of being a nurse? Since then you owe your birth to the bride-bed, and (what
was preparatory to that) the solemnizing of marriage to my waiting-woman
Madness, you cannot but acknowledge how much you are indebted to me.
Beside, those who had once dearly bought the experience of their folly,
would never re-engage themselves in the same entanglement by a second
match, if it were not occasioned by the forgetfulness of past dangers. And
Venus herself (whatever Lucretius pretends to the contrary), cannot deny,
but that without my assistance, her procreative power would prove weak
and ineffectual. It was from my sportive and tickling recreation that pro-
ceeded the old crabbed philosophers, and those who now supply their
stead, the mortified monks and friars; as also kings, priests, and popes, nay,
the whole tribe of poetic gods, who are at last grown so numerous, as in the
camp of heaven (though ne’er so spacious), to jostle for elbow room. But it
is not sufficient to have made it appear that I am the source and original of
all life, except I likewise shew that all the benefits of life are equally at my
disposal. And what are such? Why, can any one be said properly to live to
whom pleasure is denied? You will give me your assent; for there is none I
know among you so wise shall I say, or so silly, as to be of a contrary opin-
ion. The Stoics indeed contemn, and pretend to banish pleasure; but this is
only a dissembling trick, and a putting the vulgar out of conceit with it, that
they may more quietly engross it to themselves: but I dare them now to
confess what one stage of life is not melancholy, dull, tiresome, tedious, and
uneasy, unless we spice it with pleasure, that hautgoust of Folly. Of the
truth whereof the never enough to be commended Sophocles is sufficient
authority, who gives me the highest character in that sentence of his,
To know nothing is the sweetest life.
Yet abating from this, let us examine the case more narrowly. Who
knows not that the first scene of infancy is far the most pleasant and
64 — Medieval and Early Modern Europe
delightsome? What then is it in children that makes us so kiss, hug, and
play with them, and that the bloodiest enemy can scarce have the heart to
hurt them; but their ingredients of innocence and Folly, of which nature
out of providence did purposely compound and blend their tender infancy,
that by a frank return of pleasure they might make some sort of amends for
their parents’ trouble, and give in caution as it were for the discharge of a
future education; the next advance from childhood is youth, and how
favourably is this dealt with; how kind, courteous, and respectful are all to
it? and how ready to become serviceable upon all occasions? And whence
reaps it this happiness? Whence indeed, but from me only, by whose pro-
curement it is furnished with little of wisdom, and so with the less of dis-
quiet? And when once lads begin to grow up, and attempt to write man,
their prettiness does then soon decay, their briskness flags, their humours
stagnate, their jollity ceases, and their blood grows cold; and the farther
they proceed in years, the more they grow backward in the enjoyment of
themselves, till waspish old age comes on, a burden to itself as well as oth-
ers, and that so heavy and oppressive, as none would bear the weight of,
unless out of pity to their sufferings. I again intervene, and lend a helping-
hand, assisting them at a dead lift, in the same method the poets feign their
gods to succour dying men, by transforming them into new creatures,
which I do by bringing them back, after they have one foot in the grave, to
their infancy again; so as there is a great deal of truth couched in that old
proverb, Once an old man, and twice a child. Now if any one be curious to
understand what course I take to effect this alteration, my method is this: I
bring them to my well of forgetfulness, (the fountain whereof is in the For-
tunate Islands, and the river Lethe in hell but a small stream of it), and
when they have there filled their bellies full, and washed down care, by the
virtue and operation whereof they become young again. Ay, but (say you)
they merely dote, and play the fool: why yes, this is what I mean by grow-
ing young again: for what else is it to be a child than to be a fool and an
idiot? It is the being such that makes that age so acceptable: for who does
not esteem it somewhat ominous to see a boy endowed with the discretion
of a man, and therefore for the curbing of too forward parts we have a dis-
paraging proverb, Soon ripe, soon rotten? And farther, who would keep com-
pany or have any thing to do with such an old blade, as, after the wear and
harrowing of so many years should yet continue of as clear a head and
sound a judgment as he had at any time been in his middle-age; and there-
 Erasmus, The Praise of Folly — 65
fore it is great kindness of me that old men grow fools, since it is hereby
only that they are freed from such vexations as would torment them if they
were more wise; they can drink briskly, bear up stoutly, and lightly pass
over such infirmities, as a far stronger constitution could scarce master.
Sometime, with the old fellow in Plautus, they are brought back to their
horn-book again, to learn to spell their fortune in love. Most wretched
would they needs be if they had but wit enough to be sensible of their hard
condition; but by my assistance, they carry off all well, and to their respec-
tive friends approve themselves good, sociable, jolly companions. Thus
Homer makes aged Nestor famed for a smooth oily-tongued orator, while
the delivery of Achilles was but rough, harsh, and hesitant; and the same
poet elsewhere tells us of old men that sate on the walls, and spake with a
great deal of flourish and elegance. And in this point indeed they surpass
and outgo children, who are pretty forward in a softly, innocent prattle, but
otherwise are too much tongue-tied, and want the other’s most acceptable
embellishment of a perpetual talkativeness. Add to this, that old men love
to be playing with children, and children delight as much in them, to ver-
ify the proverb, that Birds of a feather flock together. And indeed what differ-
ence can be discerned between them, but that the one is more furrowed
with wrinkles, and has seen a little more of the world than the other? For
otherwise their whitish hair, their want of teeth, their smallness of stature,
their milk diet, their bald crowns, their prattling, their playing, their short
memory, their heedlessness, and all their other endowments, exactly agree;
and the more they advance in years, the nearer they come back to their cra-
dle, till like children indeed, at last they depart the world, without any
remorse at the loss of life, or sense of the pangs of death.
And now let any one compare the excellency of my metamorphosing
power to that which Ovid attributes to the gods; their strange feats in some
drunken passions we will omit for their credit sake, and instance only in
such persons as they pretend great kindness for; these they transformed
into trees, birds, insects, and sometimes serpents; but alas, their very
change into somewhat else argues the destruction of what they were before;
whereas I can restore the same numerical man to his pristine state of youth,
health and strength; yea, what is more, if men would but so far consult their
own interest, as to discard all thoughts of wisdom, and entirely resign
themselves to my guidance and conduct, old age should be a paradox, and
each man’s years a perpetual spring. For look how your hard plodding
66 — Medieval and Early Modern Europe
students, by a close sedentary confinement to their books, grow mopish,
pale, and meagre, as if, by a continual wrack of brains, and torture of inven-
tion, their veins were pumped dry, and their whole body squeezed sapless;
whereas my followers are smooth, plump, and bucksome, and altogether as
lusty as so many bacon-hogs, or sucking calves; never in their career of
pleasure be arrested with old age, if they could but keep themselves
untainted from the contagiousness of wisdom, with the leprosy whereof, if
at any time they are infected, it is only for prevention, lest they should oth-
erwise have been too happy.
For a more ample confirmation of the truth of what foregoes, it is on all
sides confessed, that Folly is the best preservative of youth, and the most
effectual antidote against age. And it is a never-failing observation made of
the people of Brabant, that, contrary to the proverb of Older and wiser, the
more ancient they grow, the more fools they are; and there is not any one
country, whose inhabitants enjoy themselves better, and rub through the
world with more ease and quiet. To these are nearly related, as well by affin-
ity of customs, as of neighbourhood, my friends the Hollanders: mine I may
well call them, for they stick so close and lovingly to me, that they are styled
fools to a proverb, and yet scorn to be ashamed of their name. Well, let fond
mortals go now in a needless quest of some Medea, Circe, Venus, or some
enchanted fountain, for a restorative of age, whereas the accurate perform-
ance of this feat lies only within the ability of my art and skill.
It is I only who have the receipt of making that liquor wherewith Mem-
non’s daughter lengthened out her grandfather’s declining days: it is I that
am that Venus, who so far restored the languishing Phaon, as to make Sap-
pho fall deeply in love with his beauty. Mine are those herbs, mine those
charms, that not only lure back swift time, when past and gone, but what
is more to be admired, clip its wings, and prevent all farther flight. So then,
if you will all agree to my verdict, that nothing is more desirable than the
being young, nor any thing more loathed than contemptible old age, you
must needs acknowledge it as an unrequitable obligation from me, for fenc-
ing off the one, and perpetuating the other.

From Desiderius Erasmus, Erasmus in Praise of Folly, Illustrated with Many Curious
Cuts, Designed, Drawn, and Etched by Hans Holbein, with Portrait, Life of Erasmus, and
His Epistle Addressed to Sir Thomas More, 8–22 (London: Reeves & Turner, 1876).
 Burton, The Anatomy of Melancholy — 67

Robert Burton
(1577–1640)

The Anatomy of Melancholy

(1621)

The writer and Anglican clergyman Robert Burton led, by his own
account, an inconspicuous, solitary life. His work The Anatomy of
Melancholy, first published in 1621, went through four editions in
his own lifetime and became one of the most cited discussions of the
subject for centuries to come. Rather than being a clinical examina-
tion of melancholy, The Anatomy is really a collection of thoughts
and reflections on the topic that had been passed down until the
early seventeenth century. In this regard, Burton gives us a sense of
the varied ways in which he and his contemporaries perceived
melancholy as well as how melancholic experiences had been dis-
cussed over time.

Melancholy, What It Is

Melancholy, the subject of our present discourse, is either in disposition or

habit. In disposition, is that transitory melancholy which goes and comes
upon every small occasion of sorrow, need, sickness, trouble, fear, grief, pas-
sion, or perturbation of the mind, any manner of care, discontent, or
thought, which causeth anguish, dulness, heaviness, and vexation of spirit,
causing frowardness in us, or a dislike. In which equivocal and improper
sense, we call him melancholy that is dull, sad, sour, lumpish, ill-disposed,
solitary, any way moved, or displeased. And from these melancholy dispo-
sitions, no man living is free, no stoic, none so wise, none so happy, none
so patient, so generous, so godly, so divine, that can vindicate himself; so
well composed, but more or less, some time or other he feels the smart of
it. Melancholy in this sense is the character of mortality. “Man that is born
of a woman, is of short continuance, and full of trouble.” Zeno, Cato,
Socrates himself, whom Aelian so highly commends for a moderate temper,
68 — Medieval and Early Modern Europe
that “nothing could disturb him, but going out, and coming in, still
Socrates kept the same serenity of countenance, what misery soever befel
him,” (if we may believe Plato his disciple) was much tormented with it.
. . . No man can cure himself; the very gods had bitter pangs, and frequent
passions, as their own poets put upon them. In general, “as the heaven, so
is our life, sometimes fair, sometimes overcast, tempestuous, and serene; as
in a rose, flowers and prickles; in the year itself, a temperate summer some-
times, a hard winter, a drought, and then again pleasant showers: so is our
life intermixed with joys, hopes, fears, sorrows, calumnies”: there is a suc-
cession of pleasure and pain. “Even in the midst of laughing there is sor-
row” (as Solomon holds). . . . And it is most absurd and ridiculous for any
mortal man to look for a perpetual tenure of happiness in this life. Nothing
so prosperous and pleasant, but it hath some bitterness in it, some com-
plaining, some grudging; it is all a mixed passion, and like a chequer table,
black and white men, families, cities, have their falls and wanes; now trines,
sextiles, then quartiles, and oppositions. We are not here as those angels,
celestial powers and bodies, sun and moon, to finish our course without all
offense, with such constancy to continue for so many ages: but subject to
infirmities, miseries, interrupted, tossed and tumbled up and down, carried
about with every small blast, often molested and disquieted upon each slen-
der occasion, uncertain brittle, and so is all that we trust unto. “And he that
knows not this is not armed to endure it, is not fit to live in this world (as
one condoles our times), he knows not the condition of it, where with a
reciprocality, pleasure and pain are still united, and succeed one another in
a ring.” Get thee gone hence if thou canst not brook it; there is no way to
avoid it, but to arm thyself with patience, with magnanimity, to oppose thy-
self unto it, to suffer affliction as a good soldier of Christ; as Paul adviseth
constantly to bear it. . . .

Symptoms, or Signs of Melancholy in the Body

Fear. Arculanus will have these symptoms to be definite, as indeed they are,
varying according to the parties, “for scarce is there one of a thousand that
dotes alike.” Some few of greater note I will point at; and amongst the rest,
fear and sorrow, which as they are frequent causes, so if they persevere
long, according to Hippocrates and Galen’s aphorisms, they are most
assured signs, inseparable companions and characters of melancholy. Many
 Burton, The Anatomy of Melancholy — 69
fear death, and yet in a contrary humor, make away themselves. Some are
afraid that heaven will fall on their heads: some they are damned, or shall
be. They are troubled with scruples of consciences, disturbing God’s mer-
cies, think they shall go certainly to hell, the devil will have them, and make
great lamentation. Fear of devils, death, that they shall be so sick of some
such or such disease, ready to tremble at every object they shall die them-
selves forthwith, or that some of their dear friends or near allies are cer-
tainly dead; imminent danger, loss, disgrace, still torment others, etc.; that
they are all glass, and therefore will suffer no man to come near them: that
they are all cork, as light as feathers; others as heavy as lead; some are afraid
their heads will fall off their shoulders, that they have frogs in their bellies,
etc. Montanus speaks of one “that durst not walk alone from home, for fear
he should swoon or die.” A second “fears every man he meets will rob him,
quarrel with him, or kill him.” A third dares not venture to walk alone, for
fear he should meet the devil, a thief, be sick; fears of all old women as
witches, and every black dog or cat he sees suspecteth to be a devil, every
person comes near him is malificiated, every creature, all intend to hurt
him, to seek his ruin; another dares not go over a bridge, come near a pool,
rock, steep hill, lie in a chamber where cross beams are, for fear he be
tempted to hang, drown, or precipitate himself. If he be in a silent auditory,
as at a sermon, he is afraid he shall speak aloud at unawares, something
indecent, unfit to be said. If he be locked in a close room, he is afraid of
being stifled for want of air. . . .
Suspicion, jealousy. Suspicion and jealousy are general symptoms: they
are commonly distrustful, apt to mistake, and amplify, testy, pettish, pee-
vish, and ready to snarl upon every small occasion. If they speak in jest, he
takes it in good earnest. If they be not saluted, invited, consulted with,
called to council, etc., or that any respect, small compliment, or ceremony
be omitted, they think themselves neglected, and contemned; for a time
that tortures them. If two walk together, discourse, whisper, jest, or tell a
tale in general, he thinks presently they mean him, applies all to himself.
Or if they talk with him, he is ready to misconstrue every word they speak,
and interpret it to the worst; he cannot endure any man to look steadily
on him, speak to him, laugh, jest, or be familiar, or hem, or point, cough,
or spit, or make a noise sometimes, etc. He thinks they laugh or point at
him, or do it in disgrace of him, circumvent him, contemn him; every man
looks at him, he is pale, red, sweats for fear and anger, lest somebody
70 — Medieval and Early Modern Europe
should observe him. He works upon it, and long after this conceit of an
abuse troubles him.
Inconstancy. Inconstant they are in all their actions, vertiginous, rest-
less, unapt to resolve of any business, they will and will not, persuades to
and fro upon every small occasion, or word spoke: and yet if once they be
resolved, obstinate, hard to be reconciled. If they abhor, dislike, or distaste,
once settled, though to be removed by odds, by no counsel, or persuasion
to be removed. Yet in most things wavering, irresolute, unable to deliber-
ate. Now prodigal, and then covetous, they do, and by and by repent them
of that which they have done, so that both ways they are troubled, whether
they do or do not, want or have, hit or miss, disquieted of all hands, soon
weary, and still seeking changes, restless, I say, fickle, fugitive, they may not
abide to tarry in one place long. . . .
Humorous. Humorous they are beyond all measure, sometimes pro-
fusely laughing, extraordinarily merry, and then again weeping without a
cause (which is familiar with many gentlewomen), groaning, sighing, pen-
sive, sad, almost distracted, they feign many absurdities, vain, void of rea-
son: one supposeth himself to be a dog, cock, bear, horse, glass, butter, etc.
He is a giant, a dwarf, as strong as an hundred men, a lord, duke, prince,
etc. And if he be told he hath a stinking breath, a great nose, that he is sick,
or inclined to such or such a disease, he believes it eftsoons, and peradven-
ture by force of imagination will work it out. Many of them are immovable,
and fixed in their conceits, others vary upon every object, heard or seen. If
they see a stage-play, they run upon that a week after; if they hear music, or
see dancing, they have nought but bagpipes in their brain; if they see a com-
bat, they are all for arms. . . . This progress of melancholy you shall easily
observe in them that have been so affected, they go smiling to themselves
at first, at length they laugh out; at first solitary, at last they can endure no
company: or if they do they are now dizzards, past sense and shame, quite
moped, they care not what they say or do, all their actions, words, gestures,
are furious or ridiculous. At first his mind is troubled, he doth not attend
to what is said, if you tell him a tale, he cries at last, what said you? but in
the end he mutters to himself as old women do many times, or old men
when they sit alone, upon a sudden they laugh, whoop, halloo, or run away,
and swear they see or hear players, devils, hobgoblins, ghosts, strike, or
strut, etc, grow humorous in the end; he will dress himself and undress,
careless at last, grows insensible, stupid, or mad. He howls like a wolf, barks
 Burton, The Anatomy of Melancholy — 71

Madness Is Deceptive (1669). This is an illustration from Der Abentheuerliche

Simplicissimus, Teutsch (The Adventurous Simplicissimus), written by Hans
Jakob Christoffel von Grimmelshausen (1621–1676). The novel, based on
Grimmelshausen’s own life, chronicles the development of a child against the
backdrop of the brutal Thirty Years’ War (1618–1648). Nuremberg. Biblio-
thèque Nationale, Paris, France. © Snark/Art Resource, NY.
72 — Medieval and Early Modern Europe
like a dog, and raves like Ajax and Orestes, hears music and outcries, which
no man else hears. . . .
Solitariness. Most part they will scarce be compelled to do that which
concerns them, though it be for their good, so diffident, so dull, of small or
no compliment, unsociable, hard to be acquainted with, especially of
strangers; they had rather write their minds than speak, and above all
things love solitariness. Are they so solitary for pleasure (one asks) or pain?
for both; yet I rather think for fear and sorrow. They delight in floods and
waters, desert places, to walk alone in orchards, gardens, private walks,
back lanes, averse from company, as Diogenes in his tub, or Timon Misan-
thropus, they abhor all companions at last, even their nearest acquain-
tances, and most familiar friends, for they have a conceit (I say) every man
observes them, will deride, laugh to scorn, or misuse them, confining them-
selves therefore wholly to their private houses or chambers, they will diet
themselves, feed and live alone. . . . But this and all precedent symptoms,
are more or less apparent, as the humor is intended or remitted, hardly per-
ceived in some, or not at all, most manifest in others. Childish in some, ter-
rible in others; to be derided in one, pitied or admired in another; to him
by fits, to a second continuate: and howsoever these symptoms be common
and incident to all person, yet they are most remarkable, frequent, furious,
and violent in melancholy men. To speak in a word, there is nothing so
vain, absurd, ridiculous, extravagant, impossible, incredible, so monstrous
a chimaera, so prodigious and strange, such as painters and poets durst not
attempt, which they will not really fear, feign, suspect, and imagine unto
themselves. . . . The tower of Babel never yielded such confusion of
tongues, as the chaos of melancholy doth variety of symptoms.

From Robert Burton, The Essential Anatomy of Melancholy (Mineola, NY: Dover,
2002), 15–17, 97–108. With the generous permission of Dover Press.
 Brydall, The Law Relating to Natural Fools — 73

John Brydall
(ca. 1635–ca. after 1705)

The Law Relating to Natural Fools,

Mad-Folks, and Lunatick Persons
(1700)

John Brydall was a conservative Oxford-trained lawyer who wrote

on a wide range of legal topics. In this commentary on English law,
Brydall set about to summarize the contemporary legal status of
those deemed to be mentally incompetent, that is, “idiots,” “mad
persons,” “lunatics,” and “drunken persons.” Since English law was
a form of customary law—meaning, it was based on historical prac-
tices rather than written statutes—Brydall relied on the writings
and statements of jurists, medical observers, and the lay public to
provide a kind of snapshot of how mental incompetence was seen at
the time.

The Author to the Reader

Seeing there have been exposed to Publick View, a couple of Tracts, the one
entituled, The Woman’s Lawyer; and the other stiled, The Infant’s Lawyer; I
have been induced to [ ] a Publication of this perexiguous [ ]iece, and have
named it, The Law of Non Compos Mentis:* It being no other than a Collec-
tion (methodically digested) of such Laws, with Cases, Opinions, and Res-
olutions, of our common Law Sages, as do properly concern the Rights of
all such, as are wholly destitute of Reason: Some whereof are become so by
a perpetual Infirmity, as Idiots, or Fools Natural: Some, who were once of
good and sound Memory, but by the Visitation of God, are deprived of it,
as Persons, in a high Degree, Distracted: Some, that have their lucid inter-
vals, (sometimes in their Wits, sometimes Out) as Lunatick Persons: And
some, who are made so by their own Default; as Persons overcome with

*Editor’s note: Non compos mentis translates as “not having mastery of one’s mind.”
74 — Medieval and Early Modern Europe
Drink, who during the time of their Drunkenness, are compared to Mad-
Folks. All which Sorts of Non Compos Mentis, are the Subject Matter of the
ensuing Sheets.
. . . Take no Pleasure in the Folly of an Idiot, nor in the Fancy of a
Lunatick, nor in the Frenzy of a Drunkard; make them the Object of thy
Pity, not of thy Pastime. When thou beholdest them, behold, how thou art
beholding to Him, that suffered thee not to be like them. This wholsome
Counsel of his, to embrace, will be look’d on as an Act of Prudence: But to
reject it, will be such a piece of Folly, as will undoubtedly bring him, that
shall be guilty of it, under the hard Sentence, of our old English Proverb, Let
him be begg’d for a Fool.

Part the First. Of him that is an Idiot Born

sec. i. an idiot or natural fool, who.

Before a Description be given of an Idiot, that from his Nativity, by a per-
petual Infirmity; is Non Compos Mentis, it will not be much amiss to give
some Account of the first Original of the Word [Idiot]; Idiota or Idiotes, is
a Greek Word, and properly signifies a private Man, who is not employed
in any Publick Office. Amongst the Latines it is taken for illiterate or fool-
ish; and hence in Cicero, and other good Authors, Idiota signifies commonly
an unlearned and illiterate Person; In Herodian, he is said to be [ ] qui rei
alicujus est imperitus, ut [ ]. But among the English Jurists, Idiot is a Term
of Law, and taken for one that is wholly deprived of his Reason and Under-
standing from his Birth; and with us in our common Speech is called a Fool
Natural; of whom there has been given a Description by several of our Law-
Authors.
Master Fitzherbert describes an Idiot thus: He who shall be said to be an
Idiot from his Birth, is such a Person, who cannot account or number twenty
pence, or cannot tell who is his Father or Mother, or how old he is, etc. So that it
may appear that he hath no understanding of Reason, what shall be for his Profit,
or what shall be his Loss.
. . . An Idiot by Civilian Swinbourn, is thus described. An Idiot, or a nat-
ural Fool is he, who notwithstanding he be of lawful Age, yet he is so witless that
he cannot number to Twenty, nor can tell what Age he is of, nor knoweth who
is his Father or Mother, nor is able to answer to any such easie Question; whereby
it may plainly appear that he hath not reason to discern what is to his profit or
 Brydall, The Law Relating to Natural Fools — 75
damage, though it be notorious, nor is apt to be informed or instructed by any
other. . . .

sec. ii. of the remarks concerning idiots

I. If a person hath so much knowledge that he can read, or learn to read
by Instruction and Information of others, or can measure an Ell of Cloth,
or name the days of the Week, or beget a Child, Son or Daughter, or such
like, whereby it may appear that he hath some light of Reason, then such a
one is no Idiot naturally. . . .
II. An Idiot or Fool Natural, is uncapable of making a Testament; nor
can he dispose of his Lands or Goods. . . .
IV. If a person be so very foolish, so very simple and sottish that he may
be made believe things incredible or impossible, as that an Ass can fly, or
that in old-times Trees did walk, Beasts and Birds could speak, as it is in
Aesop’s Fables; for he that is so foolish, cannot make a Testament because he
hath not so much wit, as a Child of ten or eleven years old, who is there-
fore intestable, namely, for want of Judgment. . . .
VI. Notwithstanding all which, if it may appear by sufficient conjec-
tures and circumstances, that such Idiots had the use of Reason and Under-
standing at such time as they did make their Testament, then are such
Testaments good and valid in law [according to Godolphin]. . . . And yet
(says the same Godolphin) if he be an Idiot indeed, albeit he may make a
wise reasonable, and sensible Testament as to the matter of it, yet it will be
void.
XIII. There is required in them who do contract Matrimony, a sound
and whole Mind to consent; for he that is either an Ideot or Madman, with-
out intermission of Fury cannot Marry. . . . This consent (saith Amesius)
must be voluntary and free, else it’s not esteemed a humane consent; and
hence the consent of such as have not the use of Reason is no force to such
a Contract. . . .
XVI. It appears in the old Books of Law, that it was expedient that
Ideots should have a Curator or Tutor, or one that should take the charge
of their Persons, Lands and Good, which Office since is devolved to the
King, and made parcel of his Prerogative. . . . As Fitzherbert very well saith,
in his Natura Brevium. The King is the Protector of all his Subjects, their
Goods, Lands and Tenements, and therefore of such as cannot govern
themselves. . . .
76 — Medieval and Early Modern Europe
Part the Second. Of him who is by
Accident wholly deprived of his Wits.

sec . i. this sort of non compos mentis how described.

He is said to be one, that was of good and sound Memory, and by the visi-
tation of God, through some Sickness, Grief, or other Accident, utterly los-
eth his Memory and Understanding; and so falls into some high, or low
degree of Fury or Madness. . . .

sec . ii. the remarks concerning mad,

or distracted persons.
I. The true account of the Cause of Distraction is this: When the Ani-
mal Spirits, by some Accident or other, are so over-heated, that they
become unserviceable to cold and sedate Reasoning; and then Reason being
thus laid aside, Fancy gets the Ascendent, and Phaeton-like, drives on furi-
ously, and inconsistently. This Combustion of the Spirits happens, some-
times by over-great Intention of the Mind, in long and constant Study;
sometimes by a Fever, which inflaming the Blood, that communicates the
Incendium to the Spirits, which take the Original from it; But most usually
by the Rage and Violence of some of the Passions (whether Irascible, or
Concupiscible, as they are wont to be distinguished) a Man setting his
Heart vehemently upon some Object or other, the Spirits are set on fire, by
the Violence of their own Motion; and in that Rage are not to be governed
by Reason. This we have sad Examples of, in Love, in Grief, in Jealousie, in
Wrath, and Vexation; and indeed, (saith my Author) Bethlehem is filled
with the Instances.
II. By the Statute of Praerogativa Regis, the King of England is to pro-
vide, that the Lands of the Furor Men be safely kept, without waste; and
that they, and their Families (if they have any) shall be maintained with the
Profits thereof; and that the Residue be kept for their use, and delivered
unto them, when they come to be of right Mind: So as their Land shall not
be aliened, neither shall the King have any profit thereof to his own use:
But if they die in such Estate, the Residue shall be distributed for their
Souls, by the Advice of the Ordinary. . . .
VI. Tho’ Furor, or Madness, hinders the contracting of Matrimony, yet
it shall not take away that Marriage that is already contracted, as appears by
the Civil and Canon Laws. . . .
 Brydall, The Law Relating to Natural Fools — 77
Part the Third. Of the Lunatick having
sometime his Reason, and sometimes not.

sec. i. the description of a lunatick,

and the word, whence derived
As for the Origination of the word Lunaticus, Lunatick, we are told, it comes
from Luna, the Moon; and so the Party is said to be Moon-sick. . . .
This Lunatick, according to the Law of England, is one, that hath some-
time his Understanding, and sometime not. . . .

sec. ii. the remarks concerning lunaticks

I. . . . Those that are born during the Interlune, or Conjunction of the
Sun and Moon, are liable to the Disease of lunacy: For, according to the
Opinion of Star-Gazers, if the Moon be ill set, or placed, it causeth Men
to be subject, either to Convulsions, to Lunacy, or the Falling-sickness:
And concerning the last of these, Physicians have a Rule, viz. They who
are troubled with the Fallingsickness, upon their good Days are not accounted
whole. . . .
III. The King of England, by his Prerogative is Summus Regni Custos, and
hath the Custody of the Person, and Estates of such, as for want of Reason
and Understanding, cannot govern themselves, or manage their Estates; so
that the Persons and Estates of Lunaticks, are as well in the Custody of the
King, as of Idiots; but with this difference: That of Idiots to his own use,
and that of Lunaticks to the use of the next Heir. . . .
XX. A Mad-man or a Lunatick, may be imprisoned by another, to pre-
vent killing of him, or burning of his House, and justifiable. The Lord
Hobart says, That the necessity of avoiding greater Inconvenience, is a good
Plea in Law; as where one kills a Thief, or a Burglar, in defence of his Per-
son, or House; so also is the binding and beating of a Person Mad or
Lunatick. . . .

sec. iii. the queries with their solutions,

relating to lunaticks
I. Whether the Testament made by a Lunatick, during his mad Fits, be
valid in Law, when he is come to himself?
Solution: Such as are Lunaticks, can make no Testament, during the
time of their Furor, or Mad Fits; no, not so much as adpios usus: Nay, the
78 — Medieval and Early Modern Europe
Testament made at such a time, shall not stand good, when the Madness is
past. . . .
VI. Whether a Lunatick be punishable for hurting a Man?
Solution: If a Lunatick kill a Man, this is no felony; because Felony
must be done, Animo Felonico; yet in Trespass, which tends only to give
Damages; according to Hurt or Loss, it is not so: And therefore if a
Lunatick hurt a Man, he shall be answerable in Trespass, and therefore no
Man shall be excused in Trespass. . . .

Part the Fourth. Of Him that is Drunken.

sec. i. a drunken man, how described.

The Fourth Sort of Non sane Memories, according to the Law of England, is
he that is Drunk; one, that (not by the visitation of God, but) by his own
vicious Act and Folly, is so overcome with Drink, that he is deprived, for a
time, of the free Use and Exercise of his Reason and Understanding. . . .

sec. ii. remarks concerning drunkenness,

and him that is drunken.
III. That which we do, being Evil, is notwithstanding by so much the
more pardonable, by how much the Exigence of so doing, or the Difficulty
of doing otherwise is greater; unless the Necessity, or Difficulty, have orig-
inally risen from our selves; it is no Excuse therefore unto him, who being
Drunk, committeth Incest, and alledgeth, that his Wits were not his own;
inasmuch as himself might have chosen, whether his Wits should by that
means have been taken from him. . . .
V. The Moralists in resolving the Quest, Whether Ebriety can excuse, or
extenuate a Fault? do make a Distinction betwixt Actual, and Habitual
Drunkenness: The former is, when any Man beside Intention, being igno-
rant as well of the Weakness of his Brain, as of the Strength of the Liquor,
is overcome with it. The latter is, when a Man is delighted with it, and
knowingly, and willingly, makes himself Drunk. That of Actual Drunken-
ness does, they say, somewhat excuse and extenuate the Fault; and conse-
quently, there is allowed some mitigation of the Punishment: But that
which is termed Habitual Drunkenness, does not at all excuse the Fault com-
mitted, nor mitigate the Punishment. . . .
 Brydall, The Law Relating to Natural Fools — 79

Laginet, Allegory: Women Have the Stones of Folly Removed from Their Husbands’
Heads. The extraction of a stone from the head to cure folly was a common
artistic motif dating back to at least the fifteenth century. There is no evidence
to suggest that this operation was actually ever performed (although trepana-
tion, or drilling into the skull, dates back to ancient times). Some medical and
art historians contend that sham extractions like this were performed by char-
latans, though there is no agreement on this point. Engraving, France, eigh-
teenth century. © Snark/Art Resource, NY.

sec. iii. the queries with their solutions,

relating to him that is drunken.
I. Whether a Man’s Drunkenness can by any good Plea in the Courts
at Westminster, either in Criminal, or Civil Acts?
Solution: The Judges, in Beverley’s Case, tho’ they have admitted a
drunken Man to be, for the time, a Non compos mentis; yet have pronounced,
that his Drunkenness shall not extenuate his Act, or Offence, not turn to
his Avail, but it is a great Offence in it self, and therefore doth aggravate
Offence, and doth not derogate from the thing he doth in that time, and
that in Case as well touching his Life, as his Goods, Chattels, or Lands, or
any other thing, concerning him. . . .
II. A Drunken Person, whether he may make a Testament?
He (saith Swinburn) that is overcome with Drink during the time of his
Drunkenness, is compared to a Mad-man; and therefore, if he make his Tes-
tament at that time, it is void in Law: Which is to be understood, when he
80 — Medieval and Early Modern Europe
is so excessively drunk, that he is utterly deprived of the use of Reason and
Understanding. Otherwise, if he be not clean spent, albeit his Understand-
ing be obscured, and his Memory troubled, yet may he make his Testament
being in that Case.

From John Brydall, Non Compos Mentis; or, the Law Relating to Natural Fools, Mad-
Folks, and Lunatick Persons Inquisited and Explained for Common Benefit (London:
Richard & Edward Aktins, 1700), A2–A3, 6–14, 52–56, 93–107, 119–124.

Hermann Boerhaave
(1668–1738)

“Aphorisms”
(1765)

Educated in both philosophy and medicine, Hermann Boerhaave

was one of the most influential physicians of the eighteenth century.
The son of a Dutch clergyman, he spent most of his life as a pro-
fessor at the University of Leyden, teaching botany, chemistry, and
medicine. In part, his influence resulted from his teaching students
from across Europe, who, in turn, imported his ideas into their
homelands. But his reputation was sealed by a number of textbooks
he wrote in which he attempted to systematize the wealth of med-
ical knowledge he had gained over the years. The following excerpts
come from lengthy commentaries made by the physician Gerhard
Freiherr van Swieten on Boerhaave’s 1709 Aphorisms on the Recogni-
tion and Treatment of Diseases. (Note that Boerhaave’s aphorisms are
followed by Swieten’s comments, which are indented below the for-
mer). The combination of aphorisms and commentaries provides an
opportunity to see how Boerhaave’s ideas were interpreted and
expanded upon over the years.
 Boerhaave, “Aphorisms” — 81
Of the Melancholy-Madness

This distemper therefore arises from that malignant indisposition of the

blood, which the ancients have termed atrabilis; and on the other hand,
when the same distemper springs primarily from the mind affected,
although the body be in health, it soon introduces a like atrabilis through-
out the habit.*

We are taught by physiology, that man is compounded of two dis-

tinct beings, united one to the other; namely, the mind, and the body,
which however different in their nature, do yet appear from undoubted
observation to be so linked one to the other, that certain thoughts of
the mind are ever united with determinate changes, or conditions of
the body; and on the contrary the same, or the like thoughts, which
spring up in the mind, without previous change of the body, are even
able to produce, especially if they stay long in the intellect, the same,
or a like change, and condition, as was excited in the will by those
ideas which first impressed their force upon the body. And although
any knowledge we have either of the body, or the mind, is insufficient
to explain why these two, so very different beings, should thus mutu-
ally actuate and influence each other, and suffer from the other, yet we
are no less certain, by experience, that this is truly matter of fact. . . .
When a woman is seized with an hysterical fit, the stomach is often
inflated, and intolerable uneasiness and anguish is thereby produced;
and that again often renders the mind so sorrowful, that sometimes life
itself is judged burdensome; but when the cramp of this convulsive
malady is relaxed, the flatulences are expelled, the anguish goes off, and
the mind recovers its former calm and serene state. But if the same
woman shall be affected with some remarkable scandal or affront, she
shall presently fall again into all like bodily complaints, although the
thoughts of the mind only were first changed as the instrumental
cause. So an inflammation only in the common membrane of the
brain, turns the modest and beneficent person into a raving madness,
from whence is urged to make fierce attacks upon every one that
comes in his way. . . .
These particulars being first considered, it now remains for us to
enquire how the atrabilis can be formed in the blood, and from what
causes it may principally proceed.

*Editor’s note: Atrabilis was another term used for black bile, thought to be a cause
of melancholy.
82 — Medieval and Early Modern Europe
If the more fluxile, or movable parts, are any way exhausted from the
entire mass of blood, the more sluggish, or immoveable parts will be left in
cohesion one with the other; whereupon the blood will become thick,
black, oily, and gross, or earthy. But to the blood thus conditioned we shall
give the name of an atrabiliary humour, or a melancholic juice.
The cause of which atrabiliary tenacity, may be every thing that expels
the more moveable parts of our juices, and fixes the rest; such as a violent
application of the mind, taken up both day and night almost upon one and
the same object; too long continued wakefulness; violent passions, or com-
motions of the mind, whether cheerful or sorrowful; violent or laborious
exercises of body, too long continued, especially in an air that is very hot
and dry; to which add immoderate venery; foods that are austere, hard, dry,
and earthy, taken for a long time under an idle or studious course of life,
with drinks of the like sort; and hitherto also belong foods of the animal
kind hardened by salting and drying in the air of smoak, and especially from
old or tough animals, with crude or unripe fruits, mealy substances not fer-
mented; medicines too astringent, coagulating, fixing, or cooling, slow poi-
sons, and the like; ardent fevers, long continued, or often returning, or
departing, without coming to a good crisis, and without the use of the
proper diluents, &c. . . .
Now whenever this vice, or tenacity, springing from its respective
causes, does as yet equally infest all the whole mass of the circulating juices,
it becomes the author of certain complaints that immediately shew them-
selves to the observation; and among these principally are the following; the
external and internal colour of the body appears first pale, then yellowish,
brown, livid, or black, with spots on the same appearance; the pulse
becomes slow, the chill, or coldness of the body is great, the breathing slow;
the circulation through the red blood vessels continues laudable; but that
through the pellucid or lateral vessels is not so free; from thence there fol-
lows a diminution of all the secretions and excretions of the humours,
which make thus a more slow thick discharge; the fluids are less wasted, the
appetite weakens, and the persons turn lean, sorrowful, and desirous of
retirement, or solitude; the passions of the mind of every sort become very
obstinate and intense; but in other matters the mind is indifferent, or
unconcerned, while the body is sluggish, or lazy towards exercise; but yet
they have an indefatigable constancy in their chosen labours and studies of
every kind. . . .
 Boerhaave, “Aphorisms” — 83
As soon as the said melancholy shews itself by the leading signs,
whether they be causes or effects, the mind is to be continually entertained
with a variation of objects, while the patient is not made acquainted with
your design; but for this such objects are to be chosen, as are commonly
known to excite passions, or affections, in the patient, perfectly contrary to
those that are at present known to prevail over him; sleep is to be recon-
ciled to him by use of medicine that are diluent, sweetening, mitigative, and
even stupifactive, or narcotic, together with silence; the air is to be rendered
warm and moist. . . .

Of the Maniacal, or Raving-Madness

If the melancholy foregoing grows up to such a heighth, as to disturb or agi-

tate the juices of the brain enough to throw the patient into violent ragings,
the distemper is then called a Mania, or the raving-madness.
The raving madness therefore differs only in degree from the more sor-
rowful melancholy, of which it is the offspring; owing its birth to the same
causes, and its cure generally to remedies almost of the like nature. . . .
But it is to be observed that by anatomical dissections the brain of such
person has appeared hard, dry, and friable, with a yellowness in its cortext;
but the vessels have been turgid, best with varices, and distended with a
tough blood.
Moreover in this distemper almost all the excretions of the body are
likewise put to a stand.
Here then, the throwing of the patient into the sea, and there keeping
him under water as long as he can bear, makes the principal remedy.

In the cure of a melancholy at §1123, and the following, such reme-

dies were recommended as by resolving or attentuating, inciting, and
stimulating the atrabiliary matter into fusion, might remove its lodg-
ments within the abdominal viscera, and cause it to be afterwards
expelled from the body. But besides these remedies, such things were
also recommended as might gradually change, and at length wholly
efface, or at least so far weaken the common idea about which the mind
is delirious, that it may not affect the common sensory more powerfully
than other ideas that are received by the senses. . . . And therefore we
see such numerous methods have been used by prudent physicians to
change the present state or condition of the sensory, by disturbing the
whole body with violent remedies and commotions. For this purpose
84 — Medieval and Early Modern Europe
hellebore, antimonial vomits, mercurials, and the like have been put in
practice, not so much to operate by evacuations, as rather by disturbing
the whole body to shake all the viscera and vessels, and by resolving all
the humours, to change their present diseased state, than which noth-
ing can be more miserable; since raving mad persons must, like wild
beasts, be confined with chains, and imprisoned from the conversation
of mankind. . . . But when all these methods have been found fruitless,
the unhappy patient must be either left to his deplorable condition, or
else plunging in the sea must be tried as the last remedy, that the
patient being almost half-dead under-water, may have all ideas extin-
guished. The success observed from this practice by physicians in the
cure of an hydrophobia, as we shall hereafter declare, seems to have been
the occasion of their putting it in force upon persons desperately mani-
acal; and promiscuous experiences have taught the happy issue of it.
...
The like remedy therefore seems applicable to the cure of a desper-
ate mania or raving madness, since the patient’s life is in no absolute
danger; namely, that by effacing all the ideas for a short time, while
there are no apparent signs of life, the latent indisposition of the com-
mon sensory, that is productive of the madness, may also be removed.
For thus sometimes, rash, or “daring experiments recover those who
are not within the compass of reasonable methods.” . . . At the same
time too it seems to appear from hence, that submersion in the sea is of
no more importance towards this end, than the submersion that is
made in any other water.

From Gerard Freiherr van Swieten, The commentaries upon the aphorisms of Dr. Her-
man Boerhaave, . . . concerning the knowledge and cure of the several diseases incident to
human bodies, Vol. 11 (London: Printed for Robert Horsfield and Thomas Longman,
1765), 4–6, 12–13, 27–28, 41–42, 132–134, 138–145.
 Cullen, Lectures on the Materia Medica — 85

William Cullen
(1710–1790)

Lectures on the Materia Medica

(1773)

William Cullen was a Scottish chemist and physician. While serv-

ing as a professor of chemistry at Edinburgh University beginning
in 1755, he also continued to have a private medical practice. In
1760–1761, he gave a series of lectures on the subject of materia
medica, a Latin term referring to those substances with therapeutic
properties in medicine (later known as pharmacology). Much to his
exasperation, an unauthorized published version of his lectures
began appearing in 1772. He was eventually convinced to authorize
a reissue of the volume with corrections.
Cullen was part of an eighteenth-century scholarly movement
that placed the human nervous system at the center of medicine.
While Boerhaave and others continued to follow the humoral tra-
dition of understanding the workings of the body in hydraulic
terms, others such as Cullen, Friedrich Hoffmann (1660–1742),
and John Brown (1735–1788) began the process of thinking about
nerves as analogous to wires. Cullen is perhaps most famous for
introducing the term neurosis to medicine.

Of all the plans of a Materia Medica, that of Boerhaave, in his posthumous

book De viribus Medicamentorum, to me seems the best. There are, indeed,
several mistakes in the introductory chapters of that performance, not to be
attributed to him, as that book was printed from erroneous notes of his
scholars. In imitation of Boerhaave, I shall begin with some physiological
observations. I am more willing to do this, as I have some peculiar notions
on this subject; and although this be no reason for thinking others in the
wrong, yet it is a very good one for explaining them here, in order that,
afterwards, I may be better understood.
86 — Medieval and Early Modern Europe
First, we adopt this maxim, viz. Medicamentum non agit in Cadaver:
because the operation of medicine does not depend on laws of matter and
motion, but on the vital principle.* We must therefore enquire into these
principles, but they run so much in a circle, that we do not know where to
begin. The circulation, however, seems to be the vital principle on which
the others depend. This leads me to examine into the cause of its motion,
namely, the heart. Some have stopped here, and considered the body entirely
as a hydraulic machine, without enquiring upon what power the contraction
of the heart depends. But this is manifestly owing to some power, inherent
in its muscular fibres, which disappear entirely soon after death. This then
may be called a vital principle, which is independent of the fluids, as the
contractile power continues after the fluids are taken away. This is not
peculiar to the heart, but common to all the muscles and contractile mem-
branes. This contractile power again is manifestly connected with nerves;
for by tying or dividing a nerve, distributed to particular muscles, it entirely
ceases in those muscles. All these nerves have a common origin from the
medullary substance, and by this we see a manifest connection between the
brain, medulla, spinalis, nerves, and moving fibres. To what extent this con-
nection goes has been much disputed. There are some experiments where
part of the brain is said to have been cut out, and the cranium stuffed with
tow, part of the brain has been wasted, by wounds and abscesses, and the
whole observed to be ossified, and, in all these cases, without great injury
to the vital functions. None of these experiments are conclusive, as we are
not sure but that some part of the medullary substance remained, sufficient
to form a common origin to all the nerves. This common origin, which may
be called sensorium commune, is connected with the soul. Here a dispute has
arisen, concerning the nature of the soul, as to its materiality, or immateri-
ality. The latter opinion is evident, from observing laws in the animal
oeconomy absolutely incompatible with mere matter and motion. . . .
The communication between the common origin of the nerves, and
sensible and moving fibres, seems to be kept up by something passing along
the nerves, in the case of the sensation from the extremity to the sensorium
commune, and in case of motion, from the latter to the former. This nervous
power seems different from everything else in our body, and seems not

*Editor’s note: Medicamentum non agit in Cadaver translates as “Medication does not
work on cadavers.”
 Cullen, Lectures on the Materia Medica — 87
peculiar to it, but a general principle in nature, particularly modified in our
system. This may be easily understood from the nature of magnetism or
electricity, which in this respect seem analogous to it.
For my part, I am not able to conceive, that a watery fluid, secreted by
the nerves, is capable of performing the actions of the body; though I do not
at all doubt, but that the brain secretes a fluid of considerable use. Our
opinion, of a general principle operating upon our system by means of the
nerves, is strengthened by what we observe in the vegetable kingdom; all
plants being, in some degree, sensible and irritable. These principles in the
vegetable oeconomy are equally difficult of solution with those in the ani-
mal, and seem to depend on the same principle.
We have now shewn, that in the fibres of animal bodies there is sensi-
bility and irritability, on which the motion of their fluids depends. This vital
power is intimately connected with the sensorium commune, and this with
the soul, which certain is of use in the medical system, though by no means
a rational conductor. The soul influences the body, not as a prime mover, but
as a modifier of external sense. . . .
In the common system great stress is laid on the laxity and rigidity of
the simple solid fibres. Although these properties are not altogether to be
disregarded, yet there are few instances of any sudden changes in the sim-
ple fibres, but they seem to increase uniformly in firmness, as the person is
advanced in age; and I have no idea of any disease in old people depending
on their laxity. I believe, in general, that it is little in our power to change
their laxity or rigidity; and that such changes ought to be imputed to an
alteration in the vital moving fibre. Application of medicines, therefore,
ought to be direct to this nervous power, and diseases, for the most part,
deduced from it. . . .
Operation of medicines depends somewhat on their own nature, but as
much on the particular modification of the system to which they are
applied. Instead, therefore, of spending time in examining the different fig-
ure of the particles of medicine, their sharpness, oilyness, etc., it will be
more useful to say somewhat on temperaments. Temperament is the gen-
eral state of the system; idiosyncrasy the peculiar state of a particular part.
The variety of temperaments is prodigious. The ancients have confined
them to four, and we, through a blind attachment to antiquity, have made
few farther advancements in this distinction. It would be difficult to enu-
merate all the different temperaments; I shall therefore consider, rather, the
88 — Medieval and Early Modern Europe
several particulars in the system that are apt to be varied in different con-
stitutions, and whose varieties constitute diversity of temperaments. These
particulars may be reduced to five: 1. The state of the simple solids. 2. The
proportion of the fluids to the solids. 3. The state of the fluids. 4. The dis-
tribution of the fluids, i.e. of particular determination to this or that part of
the system. 5. The state of the nervous power. . . .
Different state of the nervous power, with regard to sensibility, irritability,
celerity, mobility, and strength. By sensibility we mean the different forces
of impression necessary to move different persons: By irritability the extent
of the sensation, e.g. two persons, on taking the same dose of an emetic,
will be very differently affected. . . . Of the difference of sensibility we are
able to judge but grossly, as it does not depend entirely on the degree of
force impressed, but is greatly improveable by custom and practice, e.g.
there may be two persons equally sensible to the smallest impressions of
any sapid body on the tongue, and yet the one may be able only to distin-
guish green tea from bohea in infusion, while the other can not only tell a
number of different species of the same kind of tea are employed in infusion,
but also the different proportion in which the teas are employed. . . . Irri-
tability must absolutely be connected with sensibility, as being both excited
from the same cause; the one making us sensible of the simple impression,
the other propagating the sensation over the body. Irritability is often con-
nected with weakness of the nervous power; sensibility, more remarkably
with its strength: Independent of the nervous power, irritability is also var-
ied in proportion to greater or less tension of the moving fibres: The more
accurately, therefore, the vessels are filled, the fibres will be more stretched,
and the irritability greater.
Another particular, in which there may be a difference of nervous
power, is in mobility or celerity, with which actions are excited. This may be
different, even when the sensibility and irritability are the same, though it
is generally connected with them, as mobility is greater in more sensible
and irritable systems. Another variation of the nervous power is the dura-
tion of impressions. In some the effects of impression are transitory, and there-
fore the body is left open to new. This is called levity. In others these effects
are longer of duration, and the motions excited are more steady. Lastly, the
nervous power differs in strength. Some have supposed this to depend
entirely on the state of the simple fibres, and, indeed, I allow, that it is often
connected with it. But most of the changes of debility and strength are
 Cullen, Lectures on the Materia Medica — 89
owing to a change in the nervous power. Thus, at the invasion of fevers,
where we cannot suppose any change in the state of the simple fibres, we
see often remarkable debility in performing the functions, connected also
with an increased irritability. Again, in maniac persons there is often an
incredible degree of strength exerted, which cannot possibly conceive to
proceed from rigidity of simple fibres so suddenly produced. This strength
of the nervous power is opposed to sensibility, as appears from a much
stronger dose of any medicine required, to produce the same effect on the
above-mentioned maniac than other persons.

From William Cullen, Lectures on the Materia Medica (New York: Classics of Medi-
cine Library, Gryphon Editions, 1993), 2–8, 11–12.
page 90 is blank.
PART II

The Age of Optimism

While ancient, medieval, and early modern healers were far from
passive in their treatment of the mad, during this time there was
a degree of acceptance that incurable madnesses were a fact of
human existence, that the world would never rid itself of the
affliction. This viewpoint began to be challenged, however, in
the eighteenth century. The intellectual movement known as the
Enlightenment (1730–1800)—stressing a faith in the inherent
equality of men (while typically excluding women), the end of
deference to traditional authorities, confidence in the power of
reason, and trust in scientific and social progress—inspired gen-
erations of researchers, physicians, and policymakers to recon-
sider what they dismissed as their ancestors’ ignorant fatalism.
Over the course of the late eighteenth and into the nineteenth
centuries, many expressed the buoyantly optimistic sentiment
that not only could insanity be definitively understood, it could
be cured. Not everyone shared this opinion, but it spurred sci-
entific, medical, and institutional experimentation.
In the years 1770–1850, the catalysts of change were reform-
minded asylum directors, who believed that the trade of “mad-
doctoring” constituted its own worthy specialization. One of the
earliest and most famous of the mad-doctors was the Englishman
Francis Willis (1718–1807). Willis established a private lunatic
retreat in Lincolnshire for an elite clientele, offering a regimen
that stressed patient tranquility, subordination to authority, and
self-control. Reports of his success led advisors to King George
III (1760–1820)—who fell ill with a raving madness in 1788—
to call on Willis to treat the monarch. Willis’s direct appeal to

91
92 — The Age of Optimism

the intellect and emotions of his charges encouraged others,

such as William Tuke (1732–1822) and Philippe Pinel (1745–
1826), to articulate what came to be known as the “moral treat-
ment” of madness. In subsequent years, reformers on both sides
of the Atlantic drew on the example of the moral treatment to
demand what they considered to be a more holistic and humane
approach to insanity.
Although the first institutions of confinement for the insane
were constructed between 1400 and 1800, it was only over the
course of the nineteenth century that large, public asylums were
built throughout Europe and the United States. The years
1820–1870 in particular witnessed a surge in asylum building.
Whereas in 1800 only a small number of individuals were
housed in asylums, by the end of the century, France had more
than one hundred separate facilities, Germany could boast of
having two hundred state asylums along with another two hun-
dred private institutions, and the city of London alone had six-
teen asylums to call on. Historians have not agreed on the
reasons for this spurt. Was it because societies were responding
to an actual increase in mental disorders caused by moderniza-
tion? Or was it a function of the fact that states were becoming
more intolerant of disruptive behavior? Or might it have more to
do with the growing professional power of physicians and
alienists (as mad-doctors were often referred to by this time)?
Whatever the reasons for the growth, the nineteenth century
created a new image for both patient and physician, associating the
madman and the alienist with the specter of the asylum or mad-
house. The fact that asylums were often imposing structures and
deliberately placed outside residential areas only fed the popular
imagination. Lurid tales were told of horrible abuses there, and
curious sightseers found opportunities to visit facility buildings
and grounds in hopes of catching a glimpse of raving residents.
At the same time that asylums were being built, other devel-
opments were under way that quickly changed how insanity and
its treatment were viewed. The proliferation of specialized sci-
entific disciplines around 1800 and the increasing reliance of
 The Age of Optimism — 93

scholars on material explanations encouraged the growth of lab-

oratory research. Nowhere was this trend more apparent than in
Germany, where university-based institutes and clinics became
hubs for experimental research and student instruction by the
last quarter of the century. The rise there of university psychi-
atric clinics—set in urban environments and intended for the
study of a large variety of short-term patients with acute symp-
toms—encouraged a shift in professional power within psychia-
try away from alienists and toward researcher practitioners.
The impact of experimental methods on the study of human
physiology, and especially the central nervous system, was pro-
found. What began with phrenology during the first half of the
nineteenth century became the professionalized discipline of
neurology. By the 1880s, neurology’s claims about the integrated
nature of the central nervous system, the key role played by
nerve cells, and the importance of the reflex provided a new
model for understanding insanity. Seen from this perspective,
madness was not a form of mental alienation, but rather repre-
sented a nervous or brain pathology.
The scientific emphasis on nerves contributed to the popular
nineteenth-century belief that nervousness and nervous disor-
ders were rampant. Talk was of having “strong” or “weak”
nerves, of buckling under the pressures of modern life and suf-
fering “shattered nerves,” a “nervous collapse,” or “nervous
exhaustion” or having a “nervous breakdown.” The symptoms of
the nervous breakdown—typically, a sense of emptiness and
hopelessness, obsessive thoughts and anxieties, sluggishness,
and a generalized indifference—reveal the extent to which both
professionals and the lay public had come to think of the human
body electrically, as a kind of machine propelled by a fund of
nervous energy that, if one were not careful, could be danger-
ously depleted. The fact that so many of those who complained
of having nervous ailments showed no signs of an organic lesion
did not dissuade belief in their existence. Instead, physicians
simply categorized them as “functional illnesses,” requiring
alternative or future explanation.
 Enlightenment,
Romanticism,
and Reform

Philippe Pinel
(1745–1826)

A Treatise on Insanity
(1801)

In overturning the old, feudal order, the French Revolution (1789–

1799) opened up leadership positions to a new class and generation
of eager men and women schooled in Enlightenment thought. One
such individual was the physician Philippe Pinel. Born into a family
of doctors, Pinel had long criticized the traditional Paris Faculty of
Medicine for being insular and elitist, and he had been unafraid of
expressing his reformist ideas and leanings. After the revolution, as
the new government began reorganizing hospitals, poorhouses,
prisons, and schools, Pinel was recruited, in 1792, to serve as chief
physician at the Bicêtre Hospital in Paris, then asked a few years
later to become director of the Salpêtrière asylum. In both facilities,
he set about establishing what contemporaries were calling “the
moral treatment.” As the famous painting by Charles Muller shows,
the changes Pinel instituted at Bicêtre were heralded as an emblem
of enlightened Reason’s triumph over a backward Old Regime.

Nothing has more contributed to the rapid improvement of modern nat-

ural history, than the spirit of minute and accurate observation which has

94
 Pinel, A Treatise on Insanity — 95

Philippe Pinel has the irons removed from the insane at Bicêtre. Mural by
Charles Louis Muller (1815–1892). Académie de Médecine, Paris, France.
© Bridgeman-Giraudon/Art Resource, NY.

distinguished its votaries. The habit of analytical investigation, thus

adopted, has induced an accuracy of expression and a propriety of classi-
fication, which have themselves, in no small degree, contributed to the
advancement of natural knowledge. Convinced of the essential of the
same means in the illustration of a subject so new and so difficult as that
of the present work, it will be seen that I have availed myself of their appli-
cation, in all or most of the instances of this most calamitous disease,
which occurred in my practice at the Asylum de Bicêtre. On my entrance
upon the duties of that hospital, every thing presented to me the appear-
ance of chaos and confusion. Some of my unfortunate patients laboured
under the horrors of a most gloomy and desponding melancholy. Others
were furious, and subject to the influence of a perpetual delirium. Some
appeared to possess a correct judgment upon most subjects, but were
occasionally agitated by violent sallies of maniacal fury; while those of
another class were sunk into a state of stupid ideotism and imbecility.
Symptoms so different, and all comprehended under the general title of
insanity, required, on my part, much study and discrimination; and to
secure order in the establishment and success to the practice, I deter-
mined upon adopting such a variety of measures, both as to discipline and
treatment, as my patients required, and my limited opportunity permit-
ted. From systems of nosology, I had little assistance to expect; since the
arbitrary distributions of Sauvages and Cullen were better calculated to
96 — Enlightenment, Romanticism, and Reform
impress the conviction of their insufficiency than to simplify my labour.
I, therefore, resolved to adopt that method of investigation which has
invariably succeeded in all the departments of natural history, viz. to
notice successively every fact, without any other object than that of col-
lecting materials for future use; and to endeavour, as far as possible, to
divest myself of the influence, both of my own prepossessions and the
authority of others. With this view, I first of all took a general statement
of the symptoms of my patients. To ascertain their characteristic peculi-
arities, the above survey was followed by cautious and repeated examina-
tions into the condition of the individuals. All our new cases were
entered at great length upon the journals of the house. Due attention was
paid to the changes of the seasons and the weather, and their respective
influences upon the patients were minutely noticed. Having a peculiar
attachment for the more general method of descriptive history, I did not
confine myself to any exclusive mode of arranging my observations, nor
to any one system of nosography. The facts which I have thus collected
are now submitted to the consideration of the public, in the form of a reg-
ular treatise.
Few subjects in medicine are so intimately connected with the history
and philosophy of the human mind as insanity. There are still fewer, where
there are so many errors to rectify, and so many prejudices to remove.
Derangement of the understanding is generally considered as an effect of an
organic lesion of the brain, consequently as incurable; a supposition that is,
in a great number of instances, contrary to anatomical fact. Public asylums
for maniacs have been regarded as places of confinement for such of its
members as are become dangerous to the peace of society. The managers of
those institutions, who are frequently men of little knowledge and less
humanity, have been permitted to exercise towards their innocent prison-
ers a most arbitrary system of cruelty and violence; while experience affords
ample and daily proofs of the happier effect of a mild, conciliating treatment,
rendered effective by steady and dispassionate firmness. Availing them-
selves of this consideration, many empirics have erected establishments for
the reception of lunatics, and have practiced this very delicate branch of the
healing heart with singular reputation. A great number of cures have
undoubtedly been effected by those base born children of the profession;
but, as might be expected, they have not in any degree contributed to the
advancement of science by any valuable writings. It is on the other hand to
 Pinel, A Treatise on Insanity — 97
be lamented, that regular physicians have indulged in a blind routine of
inefficient treatment, and have allowed themselves to be confined within
the fairy circle of antiphlogisticism, and by that means to be diverted from
the more important management of the mind. Thus, too generally, has the
philosophy of this disease, by which I mean the history of its symptoms, of
its progress, of its varieties, and of its treatment in and out of hospitals,
been most strangely neglected.
. . . The successful application of moral regimen exclusively, gives
weight to the supposition, that, in a majority of instances, there is no
organic lesion of the brain nor of the cranium. In order however to ascer-
tain the species, and to establish a nosology of insanity, so far as it depends
upon physical derangement, I have omitted no opportunities of examina-
tion after death. . . . By these and other means, which will be developed in
the sequel, I have been enabled to introduce a degree of method into the
service of the hospital, and to class my patients in a great measure accord-
ing to the varieties and inveteracy of their complaints. . . .

Periodical Insanity Independent of the Influence of the Seasons

. . . From a general examination of the patients, at the Asylum of Bicêtre, in

the second year of the republic, which was undertaken for the purpose of
ascertaining the relative number of each variety of the disease; it appeared,
that, out of two hundred maniacs, there were fifty-two of the class subject
to paroxysms of insanity at irregular periods; and only six, whose periods of
accession observed a regular intermission. . . . I shall be excused, if I men-
tion three more cases, whose paroxysms invariably returned after an inter-
val of eighteen months, and lasted precisely six months. The peculiar
character of those unfortunate cases consisted in a few but well marked cir-
cumstances. Their ideas were clear and connected;—as they indulged in no
extravagances of fancy;—they answered with great pertinence and preci-
sion to the questions that were proposed to them: but they were under the
dominion of a most ungovernable fury, and of a thirst equally ungovernable
for deeds of blood. In the mean time, they were fully aware of their horrid
propensity, but absolutely incapable, without coercive assistance, of sup-
pressing the atrocious impulse. How are we to reconcile these facts to the
opinion which Locke and Condillac entertained with regard to the nature
of insanity, which they made to consist exclusively in a disposition to
98 — Enlightenment, Romanticism, and Reform
associate ideas naturally incompatible, and to mistake ideas thus associated
for real truths?

The Character of Maniacal Paroxysms Not Depending upon

the Nature of the Exciting Causes, but upon the Constitution

. . . I cannot here avoid giving my most decided suffrage in favour of the

moral qualities of maniacs. I have no where met, excepting in romances,
with fonder husbands, more affectionate parents, more impassioned lovers,
more pure and exalted patriots, than in the lunatic asylum, during their
intervals of calmness and reason. A man of sensibility may go there every
day of his life, and witness scenes of indescribable tenderness associated to
a most estimable virtue.

Maniacal Paroxysms Characterised by a

High Degree of Physical and Mental Energy

It is to be hoped, that the science of medicine will one day proscribe the
very vague and inaccurate expression of “images traced in the brain, the
unequal determination of blood into different parts of this viscus, the irreg-
ular movements of the animal spirits,” &c. expressions which are to be met
with in the best writings that have appeared on the human understanding,
but which do not accord with the origin, the causes, and the history of
insanity. The nervous excitement, which characterises the greatest number
of cases, affects not the system physically by increasing muscular power
and action only, but likewise the mind, by exciting a consciousness of
supreme importance and irresistible strength. Entertaining a high opinion
of his capacity of resistance, a maniac often indulges in the most extrava-
gant flights of fancy and caprice; and, upon attempts being made to repress
or coerce him, aims furious blows at his keeper, and wages war against as
many of the servants or attendants as he supposes he can well master. If
met, however, by a force evidently and convincingly superior, he submits
without opposition or violence. This is a great and invaluable secret in the
management of well regulated hospitals. I have known it prevent many fatal
accidents, and contribute greatly toward the cure of insanity. I have, how-
ever, seen the nervous excitement in question, in some few instances,
become extremely obstinate and incoercible.
 Pinel, A Treatise on Insanity — 99
The Variety and Profundity of Knowledge Requisite on the Part of
the Physician, in Order to Secure Success in the Treatment of Insanity

The time, perhaps, is at length arrived when medicine in France, now lib-
erated from the fetters imposed upon it, by the prejudices of custom, by
interested ambition, by its association with religious institutions, and by
the discredit in which it has been held in the public estimation, will be able
to assume its proper dignity, to establish its theories on facts alone, to gen-
eralise those facts, and to maintain its level with the other departments of
natural history. The principles of free enquiry, which the revolution has
incorporated with our national politics, have opened a wide field to the
energies of medical philosophy. But, it is chiefly in great hospitals and asy-
lums, that those advantages will be immediately felt, from the opportunities
which are there afforded of making a great number of observations, experi-
ments, and comparisons. . . .

The Author’s Inducements to Study the Principles of Moral Treatment

About that time I was engaged to attend, in a professional capacity, at an

asylum, where I made observations upon this disease [insanity] for five suc-
cessive years. My opportunities for the application of moral remedies, were,
however, not numerous. Having no part of the management of the interior
police of that institution, I had little or no influence over its servants. The
person who was at the head of the establishment, had no interest in the
cure of his wealthy patients, and he often, unequivocally, betrayed a desire,
that every remedy should fail. At other times, he placed exclusive confi-
dence in the utility of bathing or in the efficacy of petty and frivolous
recipes. The administration of the civil hospitals, in Paris, opened to me in
the second year of the republic a wide field of research, by my nomination
to the office of chief physician to the national Asylum de Bicêtre, which I
continued to fill for two years. In order, in some degree, to make up for the
local disadvantages of the hospital, and the numerous inconveniences
which arose from the instability and successive changes of administration,
I determined to turn my attention, almost exclusively, to the subject of
moral treatment. The hall and the passages of the hospital were much con-
fined, and so arranged as to render the cold of winter and the heat of sum-
mer equally intolerable and injurious. The chambers were exceedingly
100 — Enlightenment, Romanticism, and Reform
small and inconvenient. Baths we had none, though I made repeated appli-
cations for them; nor had we extensive liberties for walking, gardening or
other exercises. So destitute of accommodation, we found it impossible to
class our patients according to the varieties and degrees of their respective
maladies. On the other hand, the gentleman, to whom was committed the
chief management of the hospital, exercised towards all that were placed
under his protection, the vigilance of a kind and affectionate parent.*
Accustomed to reflect, and possessed of great experience, he was not defi-
cient either in the knowledge or execution of the duties of his office. He
never lost sight of the principles of a most genuine philanthropy. He paid
great attention to the diet of the house, and left no opportunity for murmur
or discontent on the part of the fastidious. He exercised a strict discipline
over the conduct of the domestics, and punished, with severity, every
instance of ill treatment, and every act of violence, of which they were guilty
towards those whom it was merely their duty to serve. He was both
esteemed and feared by every maniac; for he was mild, and at the same time
inflexibly firm. In a word, he was master of every branch of his art, from its
simplest to its most complicated principles. Thus was I introduced to a
man, whose friendship was an invaluable acquisition to me. . . .

The Advantages of Restraint upon

the Imagination of Maniacs Illustrated

A young religious enthusiast, who was exceedingly affected by the abolition

of the catholic religion in France, became insane. After the usual treatment
at the Hotel Dieu, he was transferred to the Asylum de Bicêtre.† His mis-
anthropy was not to be equaled. His thoughts dwelled perpetually upon the
torments of the other world; from which he founded his only chance of
escaping, upon conscientious adoption of the abstinences and mortifica-
tions of the ancient anchorites. At length, he refused nourishment alto-
gether; and on the fourth day after that unfortunate resolution was formed,
a state of langour succeeded, which excited considerable apprehension for

*Editor’s note: This was Jean-Baptiste Pussin (1745–1811), a tanner who himself
had been a scrofula patient in the Bicêtre Asylum in 1771 and was later cured. He
was thereafter employed by the hospital, and in 1784, he became the superintend-
ent of the ward for incurable mental patients.
†
Editor’s note: Hôtel-Dieu is one of the oldest hospitals in Paris.
 Pinel, A Treatise on Insanity — 101
his life. Kind remonstrances and pressing invitations proved equally inef-
fectual. He repelled, with rudeness, the services of the attendants, rejected,
with the utmost pernacity, some soup that was placed before him, and
demolished his bed (which was of straw) in order that he might lie upon
the boards. How was such a perverse train of ideas to be stemmed or coun-
teracted? The excitement of terror presented itself as the only resource. For
this purpose, Citizen Pussin appeared one night at the door of his chamber,
and, with fire darting from his eyes, and thunder in his voice, commanded
a group of domestics, who were armed with strong and loudly clanking
chains, to do their duty. But the ceremony was artfully suspended;—the
soup was placed before the maniac, and strict orders were left him to eat it
in the course of the night, on pains of the severest punishment. He was left
to his own reflections. The night was spent (as he afterwards informed me)
in a state of most distressing hesitation, whether to incur the present pun-
ishment, or the distant but still more dreadful torments of the world to
come. After an internal struggle of many hours, the idea of the present evil
gained the ascendancy; and he determined to take the soup. From that time
he submitted, without difficulty, to a restorative system of regimen. His
sleep and strength gradually returned; his reason recovered its empire; and,
after the manner above related, he escaped certain death. It was during his
convalescence, that he mentioned to me the perplexities and agitations
which he endured during the night of the experiment.

A Happy Expedient Employed in the Cure of a Mechanician

A celebrated watchmaker, at Paris, was infatuated with the chimera of per-

petual motion, and to effect this discovery, he set to work with indefatiga-
ble ardour. From unremitting attention to the object of his enthusiasm
coinciding with the influence of revolutionary disturbances, his imagination
was greatly heated, his sleep was interrupted, and, at length, a complete
mental derangement of the understanding took place. His case was marked
by a most whimsical illusion of the imagination. He fancied that he had lost
his head on the scaffold; that it had been thrown promiscuously among the
heads of many other victims; that the judges, having repented of their cruel
sentences, had ordered those heads to be restored to their respective own-
ers, and placed upon their respective shoulders; but that, in consequence of
an unfortunate mistake, the gentlemen, who had the management of that
102 — Enlightenment, Romanticism, and Reform
business, had placed upon his shoulder the head of one of his unhappy
companions. The idea of this whimsical exchange of his head, occupied his
thoughts night and day; which determined his relations to send him to the
Hotel Dieu. Thence he was transferred to the Asylum de Bicêtre. Nothing
could equal the extravagant overflowings of his heated brain. He sung,
cried, or danced incessantly; and, as there appeared no propensity in him to
commit acts of violence or disturbance, he was always allowed to go about
the hospital without control, in order to expend, by evaporation, the effer-
vescent excess of his spirits. “Look at these teeth,” he constantly cried,—
“Mine were exceedingly handsome;—these are rotten and decayed. My
mouth was sound and healthy: this is foul and diseased. What difference
between this hair and that of my own head. . . .”
A keen and unanswerable stroke of pleasantry seemed best adapted to
correct this fantastic whim. Another convalescent of a gay and facetious
humour, instructed in the part he should play in this comedy, adroitly
turned the conversation to the subject of the famous miracle of Saint
Denis.* Our mechanician strongly maintained the possibility of the fact,
and sought to confirm it by an application of his own case. The other set
up a loud laugh, and replied with a tone of the keenest ridicule: “Madman
as thou art, how could Saint Denis kiss his own head? Was it with his
heels?” This equally unexpected and unanswerable retort, forcibly struck
the maniac. He retired confused amidst the peals of laughter, which were
provoked at his expense, and never afterwards mentioned the exchange of
his head. Close attention to his trade for some months, completed the
restoration of his intellect. He was sent to his family in perfect health; and
has, now for more than five years, pursued his business without a return of
his complaint.

Maniacal Fury to be Repressed; but Not by Cruel Treatment

The lesions of the human intellect simply, embrace but part of the object of
the present treatise. The active faculties of the mind are not less subject to
serious lesions and changes, nor less deserving of ample consideration. The

*Editor’s note: Saint Denis was a third-century Christian martyr and bishop of
Paris. As legend has it, after Saint Denis was beheaded by opponents, he picked up
his own head and continued to preach for several miles.
 Pinel, A Treatise on Insanity — 103

Two views of circulating swings for treating insanity. Devices like these were
often used to calm acutely agitated patients. From William Saunders Hal-
laran, Practical Observations of the Causes and Cure of Insanity (Cork: Edwards
and Savage, 1818), 95. Courtesy of the National Library of Medicine,
Bethesda, MD.
104 — Enlightenment, Romanticism, and Reform
diseased affections of the will—excessive or defective emotions, passion,
&c. whether intermittent or continued, are sometimes associated with
lesions of the intellect. At other times, however, the understanding is per-
fectly free in every department of its exercise. In all cases of excessive excite-
ment of the passion, a method of treatment, simple enough in application,
but highly calculated to render the disease incurable, has been adopted
from time immemorial;—that of abandoning the patient to his melancholy
fate, as an untameable being, to be immured in solitary durance, loaded
with chains, or otherwise treated with extreme severity, until the natural
close of a life so wretched shall rescue him from his misery, and convey him
from the cells of the mad-house to the chambers of the grave. But this treat-
ment convenient indeed to a governor, more remarkable for his indolence
and ignorance than for his prudence or humanity, deserves, at the present
day, to be held up to public execration, and classed with the other preju-
dices which have degraded the character and pretensions of the human
species. To allow every maniac all the latitude of personal liberty consistent
with safety; to proportion the degree of coercion to the demands upon it
from his extravagance of behaviour; to use mildness of manners or firmness
as occasion may require,—the bland arts of conciliation, or the tone of irre-
sistible authority pronouncing an irreversible mandate, and to proscribe,
most absolutely, all violence and ill treatment on the part of the domestics,
are laws of fundamental importance, and essential to the prudent and suc-
cessful management of all lunatic institutions. But how many great quali-
ties, both of mind and body, it is necessary that the governor should
possess, in order to meet the endless difficulties and exigencies of so
responsible a situation!

From Philippe Pinel, A Treatise on Insanity, translated from the French by D. D.

Davis (Sheffield: W. Todd, 1806), 1–6, 13–14, 16, 27–28, 52–54, 61–63, 68–72,
82–83.
 Heinroth, Disturbances of Mental Life — 105

Johann Christian August Heinroth

(1773–1843)

Textbook of Disturbances of Mental Life

(1818)

The German physician J.C.A. Heinroth was among the first gener-
ation of so-called mental doctors (psychische Ärzte), a group of physi-
cians who combined the tradition of mad-doctoring with academic
learning. Having studied theology for a time, he then took up med-
icine, working in military hospitals and a workhouse before becom-
ing professor of psychotherapy (the first in Europe) at the University
of Leipzig in 1811. Along with a host of other prominent asylum
directors and physicians in Germany at the time, Heinroth was influ-
enced by the intellectual movement of Romanticism, which empha-
sized values such as reason, the unity of mind and body, spiritual
growth, and moral awakening. For him, madness was the result of
an alienation from nature, a condition he believed was inherent to
modern life. Although rarely acknowledged today, Heinroth and the
other Romantic mental doctors were enormously influential in the
nineteenth century, responsible for coining the term psychosomatic
and developing the concept of the conflicted personality—notions
that would later be taken up by Sigmund Freud. The following
excerpt from Heinroth’s textbook explains his general understanding
of mental health and illness as well as the kind of role he believed
the mental doctors needed to play in treating those in their care.

The Concept of Disturbed Mental Life or Disturbances of the Soul

The development of human life through all its ages may be considered as a
journey made at a measured pace and aimed at the highest consciousness
or life of reason; nay, one is forced to this conclusion or else to consider that
man, with all the tendencies and forces which determine his life, is a crea-
ture which spends its existence in perpetual self-contradiction. The free
creative force in man, his imagination, at first resembles the still amorphous
106 — Enlightenment, Romanticism, and Reform
sap of plants which rises by way of roots, stem, branches, and leaves, is
purified and transformed into flowers and fruit. The mental life of a child is
sensual, and the imagination of the child exercises itself in the sensual
world in play. The play urge is the child’s expression of love. The mental
life of the age of youth is also wholly dedicated to the imagination and con-
centrates the entire activity of the creative force on one point, on one
object, viz., beauty; the beauty urge is the expression of love in youth. Not
necessity but love is also the mother of the arts which originate from the
individual man and from the human race, inasmuch as the individual and
society live and love in the way of the young. The mental life of the mature
age extends all the accumulated and complete activities of the creative force
into the broad spheres of life with the aid of reason, and it is the business
of this age to understand and to bring order, to enlighten and to control,
and to stand free and independent through reason or at least to strive for
freedom and independence. The urge for freedom is the expression of love
of mental life at its zenith. . . .
This is the way man ought to grow. We learn this through faithful
observation of his developing urge for growth in a regular determined form.
But man is not a plant, and natural necessity is not his all-powerful master.
Even though his conscience, his supreme law, affects him with all the sever-
ity of a natural necessity, he is nevertheless free not to obey it. Thus he is
the first and the only creature on this earth who is a free agent. . . .
The Divine intentions in man are frustrated by man himself in many
different ways. The way to the highest development in world-consciousness
and in self-consciousness leads through the senses, imagination, and rea-
son, but human life must not become arrested at the lower stages of devel-
opment and refuse the Divine summons to proceed to higher stages. The
man who scorns this repeated summons and is content with and stays only
in the non-Divine existence and life will become enslaved by the non-
Divine and lose his free will; this loss will not be direct or immediate, but
the only possible truly free condition of life, and with it the feeling of pure
satisfaction and joy, will be lost to him. A prey to passions, madness, and
vice, the creative processes will be impeded, halted, and forced back in many
different ways. Thus, by observing such a disturbed process of the inner
organization that should have served to sustain the complete life, that is,
the free life, we arrive at the concept of a disturbed mental life, or, in short,
disturbance of the soul.
 Heinroth, Disturbances of Mental Life — 107
This concept is as yet very general, and no definite meaning has so far
been assigned to it. It means nothing more than a mental life impeded in
some way in its normal growth. Thus, any diseased condition could be
denoted as mental disturbance. However, it must be borne in mind that
passion, madness, and even vice often assist the soul of a man who, admon-
ished by the voice of his conscience heard through the dim fog of his con-
dition, may gather his forces, break his chains, and rise to a freer, higher
plan and pursue good with a greater will. Furthermore, in any soul which
still retains its free will, that is, at least potentially free, and which is
enslaved by some but not all relationships of life (for good seed often bears
fruit in the midst of weeds), the condition of the disturbance, the whole
interference with the inner life, is neither complete nor exhaustive. There-
fore the concept of disturbance of the soul must be understood more pre-
cisely as a total halt, a total standstill, or else an innate desire of the creative
force, which was originally intended to produce the highest development,
for the opposite, that is, for self-destruction, and must be restricted to cases
in which such signs are distinctly evident.
In this condition the free will exists no more and is replaced by com-
plete and permanent loss of freedom. This condition prevails in diseases
commonly known as mental breakdown, aberrations of reason, madness,
disease of temperament, mental diseases in general, etc. All these diseases,
however, much as their external manifestations may differ, have this one
feature in common, namely, that not only is there no freedom but not even
the capacity to regain freedom. The world-consciousness and the self-con-
sciousness are to a greater or lesser extent disturbed, confused, or wholly
extinct, while there is no room for the reasoned consciousness, since free
will, which is the receptacle of this consciousness, has died. Thus, individ-
uals in this condition exist no longer in the human domain, which is the
domain of freedom, but follow the coercion of internal and external natural
necessity. Rather than resembling animals, which are led by a wholesome
instinct, they resemble machines and are maintained by vital laws in bodily
life alone.

The Concept of Doctor of the Psyche

If we assume that it is possible to cure mental disturbances, or at least to

cure some of them under certain conditions, there arises the following
108 — Enlightenment, Romanticism, and Reform
question. Since it is the degenerate mental life which must be led back to
normal, since it is the humanly healthy condition which must be restored,
would this be the task of a doctor? or perhaps of a cleric? of a philosopher?
or of an educator? There are arguments which speak in favor of each of
these four viewpoints, and each of these professions is at least apparently
entitled to take possession of this curative task. . . .
Since we are speaking of medical art and science, we should think
that nobody but a doctor should have a right to make mental distur-
bance the object of his studies and treatment. Indeed, doctors have
claimed this right in their compendia and practice. . . . Nevertheless,
since we are claiming that mental disturbances are the opposite of
human health and since this claim is not arbitrary but stems from a
faithful observation of human nature, we must separate the entire sphere
of manifestations from the forms of illness which have symptoms the
doctors are accustomed to diagnose. We must transfer them to another
domain, the domain of mental life, with which doctors (since they are
only familiar with bodily nature) are not familiar with regard to both the
recognition of the disease and its treatment. The medical studies to be
indicated below testify to this complete ignorance; furthermore, the
point of view and the sphere of activity for which doctors are trained and
prepared at high schools of learning and at the sickbed are totally differ-
ent from the legitimate and true ones given in the present textbook.
Accordingly, since doctors are pupils and adepts of medicinal art and sci-
ence in the field of disturbed bodily lives only, they are not directly and
immediately suited, at least not in the present condition of both educa-
tion and experience as practicants, to carry out the business of healing
the psyche.
The clerics, as the recognized shepherds of the soul, are just as unfit for
the tasks, owing to their point of view and the training and direction they
have received. For their field of activity is the moral nature of man for as
long as it exists and not after it has died or at least temporarily disappeared.
Their business, their profession, is thus concerned with a sphere which is
quite different from the one which the doctor of the soul must be familiar.
Philosophers, especially psychologists, have at times ventured into the
sphere of disturbed mental life, at least theoretically, but they cannot
accomplish anything, even in the theory of mental disturbances alone,
unless they apply themselves to a faithful observation of nature. This has
 Heinroth, Disturbances of Mental Life — 109
not yet happened, as will be demonstrated later. Since their activity is con-
fined to the writing desk, nothing in the nature of practical work can be
expected of them, whereas the purpose of medicine of the psyche is pre-
cisely to take action in order to teach the art of guiding the disturbed men-
tal life back to normal.
This science and art has much more in common with the art of an edu-
cator, even doctors agree that curing mentally disturbed individuals is at the
same time a reeducation. But all will consent, at least, that this science and
art was not invented by educators, even if it already existed; and educators,
just like clerics, are at present trained and prepared to deal with free human
force, but not to restore a freedom which has been lost. . . .
However, these requirements, or at least some of them, are such as can
never be met by an educator or by a cleric or by a philosopher. For the doc-
tor of the psyche must first be a physician, in the full ordinary meaning of
the word. He must be learned in the medical traditions and versed in med-
ical practice, partly because mental disturbances are often accompanied by
bodily disturbances which they excite, maintain, and modify, partly because
in very many instances it is possible to influence the mentally disturbed
only through their bodies. It must therefore be concluded that the doctor
of the psyche must indeed come forth from the class of physicians. We are
purposely saying come forth, for he must not remain in this class, firstly
because this class is sufficiently occupied in its own field, whereas the field
of soul medicine is so large that the forces of an active man are fully engaged
therein; secondly because a doctor of the psyche must undergo special
training and must go in a direction which is altogether different from that
of the doctor of the body.
For whoever takes upon himself to be a doctor of the psyche must be
specially schooled by the psychologist, by the cleric, and by the educator;
or rather, he must develop in himself the gift for psychological observation,
must adopt a religious point of view, and must himself attempt to live the
life of a cleric, or such a life as a pious man would live, that is, to lead a life
of reason, or, in the words of the Holy Writ, a life in Christ, or must walk
in light, all of which is the same thing. Finally, he must become proficient
in the methods of the educator, transform them to his own ends, and carry
them over into his own sphere. . . .
This is what a doctor of the psyche, or rather one who has committed
himself to being one, must do. Reason is the organ of any recognition and
110 — Enlightenment, Romanticism, and Reform
ought to be developed not only by a physician but by all men. This in fact
happens very seldom, which explains why our knowledge and our actions
are so often blundering. Whoever does not live in light lives in darkness
(and a deceptive light, say, the light of a false philosophy, is also darkness),
and it is the purpose of the doctor of the soul to bring the mentally dis-
turbed, whose inner life is totally darkened, back to light. But how can he
do this if he himself does not live in light? It is necessary to sharply empha-
size this point of view of the doctor of the soul. Whoever cannot make this
point of view his own must give up the name and the power and the busi-
ness of a doctor of the soul.
Thus, the doctor of the soul (or psyche) is a true man of reason. He
has overcome his selfish interests and treats for purely humanitarian rea-
sons. He considers his patients only as sufferers and not in relation to his
own personality. Much is gained even by this attitude alone, since in this
manner he obtains an unprejudiced, correct view. He does not hold the vul-
gar and limited view according to which it is the bodily relationships which
determine both the disturbance and the cure, but will concentrate on the
soul life and will view all diseased manifestations of the psyche in relation
to the latter. From the very outset he influences the patient by virtue of his,
one may be permitted to say, holy presence, by the sheer strength of his
being, his glance and his will. The will exists in man as a force which is not
cultivated; it is however the will which gives rise to all creation, and man,
too, has his share of this creative force. The will is the principle of miracles,
the principle of magnetism. The magnetic manipulation is only an ad hoc
device, a kind of mechanical stimulant of the will. But will without spirit is
blind, and will without temperament is barren. The man of reason com-
bines all forces of his inner being for a full understanding and for the living
deed. Sapere aude!*

From Johann Christian August Heinroth, Textbook of Disturbances of Mental Life; or,
Disturbances of the Soul and Their Treatment, translated by J. Schmorak, introduction
by George Mora, vol. 1, Theory (Baltimore: Johns Hopkins University Press, 1975),
19–29. © The Johns Hopkins University Press. Reprinted with permission of The
Johns Hopkins University Press.

*Editor’s note: “Dare to know!”

 Esquirol, “Monomania” — 111

Jean Etienne Esquirol

(1772–1840)

“Monomania”
(1838)

Esquirol was a student of Philippe Pinel, whom he succeeded as

director at the Salpêtrière Hospital in Paris in 1811. Expanding on
Pinel’s thinking, Esquirol believed that dealing with madness
required a host of social and legal reforms, and he eventually became
the chief architect of France’s modern asylum system. Enamored
with nosology (the science of disease classification), one of his lega-
cies was to develop the diagnosis of monomania. Up until the turn
of the nineteenth century, physicians, legislators, and courts tended
to see insanity as a defect of reason, namely, the problem rested in
the individual’s inability to rationally comprehend. Esquirol’s inno-
vation was to argue that a person’s emotions or will power could be
impaired, without affecting his or her ability to reason. The diag-
nosis of monomania was an attempt to come to grips with this pos-
sibility. In the decades that followed, it provided the inspiration for
concepts such as obsession and psychopathy.

Monomania

After having set forth characteristics of lypemania (melancholy with delir-

ium), it becomes my duty to describe that form of partial delirium, to which
I have given the name monomania; but first, I will endeavor to point out the
distinctive characteristics of those two forms of delirium. Monomania and
lypemania, are chronic cerebral affections, unattended by fever, and charac-
terized by a partial lesion of the intelligence, affections, or will. At one time,
the intellectual disorder is confined to a single object, or a limited number
of objects. The patients seize upon a false principle, which they pursue
without deviating from logical reasonings, and from which they deduce
legitimate consequences, which modify their affections, and the acts of their
112 — Enlightenment, Romanticism, and Reform
will. Aside from this partial delirium, they think, reason and act, like other
men. Illusions, hallucinations, vicious associations of ideas, false and
strange convictions, are the basis of this delirium, which I would denomi-
nate, intellectual monomania. At another; monomaniacs are not deprived of
the use of their reason, but their affections and dispositions are perverted.
By plausible motive, by very reasonable explanations, they justify the actual
condition of their sentiments, and excuse the strangeness and inconsis-
tency of their conduct. It is this, which authors have called reasoning mania,
but which I would name affective monomania.
In a third class of cases, a lesion of the will exists. The patient is drawn
away from his accustomed course, to the commission of acts, to which nei-
ther reason nor sentiment determine, which conscience rebukes, and
which the will has no longer the power to restrain. The actions are invol-
untary, instinctive, irresistible. This is monomania without delirium, or,
instinctive monomania. . . .
M. H., forty-five years of age, a bachelor, and counsellor-at-law, is of a
medium stature, bilious-sanguine temperament, of an excellent constitu-
tion, and has a remarkably voluminous head. His forehead is uncovered to
a very considerable extent, his hair black, his eyes full of vivacity, and his
complexion swarthy. He has always led a regular life, and conducted his
affairs with system and integrity. He resided for some time at Guadeloupe,
was sick for a year after a struggle with the climate, in connection with
reverses of fortune, was sent back to Paris, and admitted to Charenton,
Nov. 20th, 1832. During the first months of his sojourn at this establish-
ment, he appears composed, walking in the garden, reading much, and con-
versing with spirit. He would have been regarded as rational, if, from time
to time, his delirium did not make itself manifest. He called himself the son
of Louis XVI, and was accustomed to add, that an attempt had been made
to poison him, for political purpose. After some months, the delirium man-
ifests itself more habitually, and at length reaches a state of fury. He is king,
and as such, expects to command and to be obeyed. Those who surround
him are his slaves, and their right to life and death is vested in him. Wo to
the man who accosts him, without recognizing his kingly power. A doubt
on this point, is high treason. The domestics who serve him, know full well
the precautions which it is necessary to take, in presenting themselves to
him. In several instances, his threats and transports of passion, on my
endeavoring to combat his error, have put me on my guard.
 Esquirol, “Monomania” — 113
In his case, every circumstance comports with his conviction. His lofty
carriage, his attitude and look; the imperious tone of his voice and gestures,
most clearly express the vain prejudices that occupy his mind. He does not
adorn himself with the insignia of his rank, and with ribbons, after the man-
ner of monomaniac kings with whom we meet among assemblages of the
insane; but the walls of his cell, which he regards as a dungeon, present,
written in large characters, both words and phrases, which disclose his
mental condition. Observe some of the inscriptions, which he has traced in
the form of letters, as they stand upon the walls:
I have–. Tuesday–. A rabble of Frenchmen–. Farther on: Mortal hatred to
the French Nation,– to the people, to the Nobility–by S.A.R., Prince of Bour-
bon, etc. April 1st, 1837: Son of Louis XVI.– King. Below: I am not a
Man—but a Prince—King—monarch.
This hatred of the French, and these titles which he proclaims with
pride, constitute the subject of all his letters and writings. He feels indignant
at the injustice that restrains him by prison bolts; so great and powerful as
he is. He pretends that they have taken possession of him by supernatural
means, which spies,—selected from the most degraded of the French peo-
ple—employ; by pouring upon his majesty, torrents of electricity, in order to anni-
hilate him. Sometimes he refuses food, not wishing to be nourished like the
clowns of his corridor. His food ought to be prepared in royal kitchens. His
grandeur and power permit him to recognize, as his relatives and friends,
none other than the Bourbons, Ferdinands, Nicholases, etc. . . .
Monomaniacs, like other insane persons, are subject to illusions and
hallucinations, which often alone characterize their delirium, and are the
causes of the perversion of their affections, and the disorder of their actions.
Numerous facts justify this statement. Transported by enthusiasm, by reli-
gious or political fanaticism, warmed by erotic passions, blinded by notions
of an imaginary good fortune, flattered by sentiments of a felicity of which
they deem themselves alone worthy, monomaniacs entertain little affection
for their relatives and friends, or their tenderness is exaggerated. They often
disdain persons whom they are accustomed to love most tenderly, and feel
a sort of pity for them, in consequence of their pretended ignorance, or sup-
posed poverty, or because they are unworthy of understanding the good for-
tune of the monomaniac, or of participating in it. Like all insane persons,
these patients neglect their own interest and affairs, and treat with con-
tempt the usages of society. There are insane persons in conformity with
114 — Enlightenment, Romanticism, and Reform
the strictest principles, remarkable for the rectitude of their understanding,
for the delicacy of their sentiments, for the mildness of their dispositions,
and for a uniformly sober and moral life; who, in consequence of some
physical or moral causes, change their disposition and habits of conduct,
become turbulent and unsociable, and perform odd, singular, culpable, and
sometimes dangerous acts, in opposition to their affections and interests. A
partial lesion of the understanding causes these changes, and perverts the
sentiments and actions of this class of patients. Thus, the old man, who
believes that he hears the voice of an angel, who commands him to offer up
his son, after the example of Abraham, and perform this sacrifice, is a
monomaniac. . . .
The causes which predispose and produce monomania, are the same
with those which produce insanity in general. Sanguine and nervous-
sanguine temperaments, and persons endowed with a brilliant, warm and
vivid imagination; minds of a meditative and exclusive cast, which seem to
be susceptible only of a series of thoughts and emotions; individuals who,
through self-love, vanity, pride and ambition, abandon themselves to their
reflections, to exaggerated projects and unwarrantable pretensions, are
especially disposed to monomania. It is remarkable, that these individuals
almost invariably beguile themselves with the hope of a happy fortune,
when, stricken by some reverse, or disappointed in their lofty expectations,
they fall sick. Thus, a man who is actually happy, and moderate in his
desires, and who, by some exciting cause, becomes insane, will not be a
monomaniac; whilst an ambitious, proud, or amorous man, who shall have
become unfortunate, or have lost the object of his affections, will. It would
seem as if monomania were only an exaggeration of the thoughts, desires
and illusions with respect to the future, with which these unfortunate
beings amuse their fancy, previous to their illness.
A weak understanding, little cultivated or developed; and the want, or
vices of education, also predispose to monomania. The exciting causes are;
errors of regimen, strong passions, and especially reverses of fortune, dis-
appointed self-love, or ambition. Religious excitement also, ascetic medita-
tions and the reading of romances, often produce this disease among those
who are essentially controlled by pride and vanity. . . . Monomania is remit-
tent or intermittent; and the symptoms are exasperated, particularly at the
menstrual periods. It is sometimes preceded by melancholy and lypemania,
and is complicated with epilepsy, hysteria, hypochondria, and very fre-
 Esquirol, “Monomania” — 115
quently with paralysis. The progress of monomania is rapid and violent. Its
termination is often unexpected, and is effected like other forms of mental
alienation, by crises, more or less sensible. But it not unfrequently termi-
nates suddenly, without cause, or perceptible crisis, or by a vivid moral
impression. Monomania sometimes passes into mania, and sometimes
alternates with lypemania. When prolonged, it degenerates into dementia.
. . . But when the disease degenerates into a chronic state, the monomaniac
is not only irrational in his hypothesis, but his reasonings, affections and
acts, which were previously, the proper consequences of the idea or con-
trolling affection of his mind, no longer maintain their logical and natural
connection. . . . The treatment of monomania should, as in other forms of
mental alienation, be directed with a special reference to the predisposing
and exciting causes of the disease, and to the physical disorders. The intel-
lectual and moral symptoms should have great weight in the therapeutic
views of the physician. In this malady, which is characterized by a peculiarly
nervous condition of the system, antispasmodics are very useful. While we
may, with advantage, have recourse to hygienic agents, it is proper also, to
hope for success from moral treatment. Here, more than in other forms of
mental disease, and with better hopes of success, we apply to the under-
standing and passions of the patient, with a view to effect his cure. We have
recourse to surprises, subterfuges, and oppositions, ingeniously managed,
as circumstances suggest, the genius of the physician gives birth to, and as
experience may hit upon, and appropriately pursue.

From E. Esquirol, Mental Maladies: A Treatise on Insanity (Philadelphia: Lea and

Blanchard, 1845), 320, 327–328, 333–334.
116 — Enlightenment, Romanticism, and Reform

Dorothea Dix
(1802–1887)

Memorial to the Legislature

of Massachusetts
(1843)

Dorothea Dix was one of the early American activists for prisoners
and the insane poor. The daughter of an itinerant preacher, she had
the opportunity in 1836 to travel to England, where she became
familiar with the ideas of the prison reformer Elizabeth Frye
(1780–1845) and the reform-minded asylum director Samuel Tuke
(1784–1857). After returning to the United States, she happened
to examine accommodations for the insane at the Cambridge, Mass-
achusetts, jail and was appalled to find the inmates there chained up
in dungeon cells. She then set about touring poorhouses, jails, and
prisons to investigate conditions elsewhere, first traveling from
county to county, then from state to state. Her findings led her to
publicly advocate for the reform of state institutions of confinement.
In the 1850s, she took her mission overseas to Britain, France,
Greece, Russia, and Japan. All in all, Dix proved to be one of the
most internationally respected and effective reformers of the nine-
teenth century. The following excerpt comes from her 1843 appeal
to the state legislature of Massachusetts.

gentlemen.
I respectfully ask to present this Memorial, believing that the cause,
which actuates to and sanctions so unusual a movement, presents no equiv-
ocal claim to public consideration and sympathy. Surrendering to calm and
deep convictions of duty my habitual views of what is womanly and becom-
ing, I proceed briefly to explain what has conducted me before you unso-
licited and unsustained, trusting, while I do so, that the memorialist will be
speedily forgotten in the memorial.
 Dix, Memorial to the Legislature of Massachusetts — 117
About two years since leisure afforded opportunity, and duty
prompted me to visit several prisons and alms-houses in the vicinity of this
metropolis. I found, near Boston, in the Jails and Asylums for the poor, a
numerous class brought into unsuitable connexion with criminals and the
general mass of Paupers. I refer to Idiots and Insane persons, dwelling in
circumstances not only adverse to their own physical and moral improve-
ment, but productive of extreme disadvantages to all other persons
brought into association with them. I applied myself diligently to trace the
causes of these evils, and sought to supply remedies. As one obstacle was
surmounted, fresh difficulties appeared. Every new investigation has given
depth to the conviction that it is only by decided, prompt, and vigorous
legislation the evils to which I refer, and which I shall proceed more fully
to illustrate, can be remedied. I shall be obliged to speak with great plain-
ness, and to reveal many things revolting to the taste, and from which my
woman’s nature shrinks with peculiar sensitiveness. But truth is the high-
est consideration. I tell what I have seen—painful and shocking as the
details often are—that from them you may feel more deeply the impera-
tive obligation which lies upon you to prevent the possibility of a repeti-
tion or continuance of such outrages upon humanity. If I inflict pain upon
you, and move you to horror, it is to acquaint you with sufferings which
you have the power to alleviate, and make you hasten to the relief of the
victims of legalized barbarity.
I come to present the strong claims of suffering humanity. I come to
place before the Legislature of Massachusetts the condition of the miser-
able, the desolate, the outcast. I come as the advocate of helpless, forgotten,
insane and idiotic men and women, sunk to a condition from which the
most unconcerned would start with real horror; of beings wretched in our
Prisons, and more wretched in our Alms-Houses. And I cannot suppose it
needful to employ earnest persuasion, or stubborn argument, in order to
attest and fix attention upon a subject, only the more strongly pressing in
its claims, because it is revolting and disgusting in its details.
I must confine myself to few examples, but am ready to furnish other
and more complete details, if required. If my pictures are displeasing,
coarse, and severe, my subjects, it must be recollected, offer no tranquil,
refined, or composing features. The condition of human beings, reduced to
the extremest states of degradation and misery, cannot be exhibited in soft-
ened language, or adorn a polished page.
118 — Enlightenment, Romanticism, and Reform
I proceed, Gentlemen, briefly to call your attention, to the present state
of Insane Persons confined within this Commonwealth, in cages, closets, cel-
lars, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience!
As I state cold, severe facts, I feel obliged to refer to persons, and defi-
nitely to indicate localities. But it is upon my subject, not upon localities or
individuals, I desire to fix attention; and I would speak as kindly as possible
of all Wardens, Keepers, and other responsible officers, believing that most
of these have erred not through hardness of heart and willful cruelty, so
much as want of skill and knowledge, and want of consideration. Familiar-
ity with suffering, it is said, blunts the sensibilities, and where neglect once
finds a footing other injuries are multiplied. This is not all, for it may justly
and strongly be added that, from the deficiency of adequate means to meet
the wants of these cases, it has been an absolute impossibility to do justice
in this matter. Prisons are not constructed in view of being converted into
County Hospitals, and Alms-Houses are not constructed as receptacles for
the Insane. And yet, in the face of justice and common sense, Wardens are
by law compelled to receive, and the Masters of Alms-Houses not to refuse,
Insane and Idiotic subjects in all stages of mental disease and privation.
It is the Commonwealth, not its integral parts, that is accountable for
most of the abuses which have lately, and do still exist. I repeat it, it is defec-
tive legislation which perpetuates and multiplies these abuses.
In illustration of my subject, I offer the following extracts from my
Note-Book and Journal. . . .
The use of cages all but universal; hardly a town but can refer to some
not distant period of using them; chains are less common; negligences fre-
quent; willful abuse less frequent than sufferings proceeding from igno-
rance, or want of consideration. I encountered during the last three months
many poor creatures wandering reckless and unprotected through the
country. Innumerable accounts have been sent me of persons who had
roved away unwatched and unsearched after; and I have heard that respon-
sible persons, controlling the almshouses, have not thought themselves
culpable in sending away from their shelter, to cast upon the chances of
remote relief, insane men and women. These, left on the highways,
unfriended and incompetent to control or direct their own movements,
sometimes have found refuge in the hospital, and others have not been
traced. But I cannot particularize; in traversing the state I have found hun-
dreds of insane person in every variety of circumstance and condition;
 Dix, Memorial to the Legislature of Massachusetts — 119
many whose situation could not and need not be improved; a less number,
but very large, whose lives are the saddest pictures of human suffering and
degradation. I give a few illustrations; but description fades before reality.
Danvers. November; visited the almshouse; a large building, much out
of repair; understand a new one is in contemplation. Here are fifty-six to
sixty inmates; one idiotic; three insane; one of the latter in close confine-
ment at all times.
Long before reaching the house, wild shouts, snatches of rude songs,
imprecations, and obscene language, fell upon the ear, proceeding from the
occupant of a low building, rather remote from the principal building to
which my course was directed. Found the mistress, and was conducted to
the place, which was called “the home” of the forlorn maniac, a young woman,
exhibiting a condition of neglect and misery blotting out the faintest idea of
comfort, and outraging every sentiment of decency. She had been, I learnt,
“a respectable person; industrious and worthy; disappointments and trials
shook her mind, and finally laid prostrate reason and self-control; she
became a maniac for life! She had been at Worcester Hospital for a consid-
erable time, and had been returned as incurable.” The mistress told me she
understood that, while there, she was “comfortable and decent.” Alas! what
a change was here exhibited! She had passed from one degree of violence
and degradation to another, in swift progress; there she stood, clinging to,
or beating upon, the bars of her caged apartment, the contracted size of
which afforded space only for increasing accumulations of filth, a foul spec-
tacle; there she stood with naked arms and disheveled hair; the unwashed
frame invested with fragments of unclean garments, the air so extremely
offensive, though ventilation was afforded on all sides save one, that it was
not possible to remain beyond a few moments without retreating for recov-
ery to the outward air. Irritation of body, produced by utter filth and expo-
sure, incited her to the horrid process of tearing off her skin by inches; her
face, neck, and person, were thus disfigured to hideousness; she held up a
fragment just rent off; to my exclamation of horror, the mistress replied,
“Oh, we can’t help it; half the skin is off sometimes; we can do nothing with
her; and it makes no difference what she eats, for she consumes her own
filth as readily as the food which is brought her.”
It is now January; a fortnight since, two visitors reported that most
wretched outcast as “wallowing in dirty straw, in a place yet more dirty, and
without clothing, without fire. Worse cared for than the brutes, and wholly
120 — Enlightenment, Romanticism, and Reform
lost to consciousness of decency!” Is the whole story told? What was seen
is; what is reported is not. These gross exposures are not for the pained
sight of one alone; all, all, coarse, brutal men, wondering, neglected chil-
dren, old and young, each and all, witness the lowest, foulest state of mis-
erable humanity. And who protects her, that worse than Paria outcast, from
other wrongs and blacker outrages? I do not know that such have been. I do
know that they are to be dreaded, and that they are not guarded against.
Some may say these things cannot be remedied; these furious maniacs
are not to be raised from these base conditions. I know they are; could give
many examples; let one suffice. A young woman, a pauper, in a distant town,
Sandisfield, was for years a raging maniac. A cage, chain, and the whip, were
the agents for controlling her, united with harsh tones and profane lan-
guage. Annually, with others (the town’s poor) she was put up at auction,
and bid off at the lowest price which was declared for her. One year, not
long past, an old man came forward in the number of applicants for the
poor wretch; he was taunted and ridiculed; “what would he and his old wife
do with such a mere beast?” “My wife says yes,” replied he, “and I shall take
her.” She was given to his charge; he conveyed her home; she was washed,
neatly dressed, and placed in a decent bed-room, furnished for comfort and
opening into the kitchen. How altered her condition! As yet the chains were
not off. The first week she was somewhat restless, at times violent, but the
quiet kind ways of the old people wrought a change; she received her food
decently; forsook acts of violence, and no longer uttered blasphemous or
indecent language; after a week, the chain was lengthened, and she was
received as a companion into the kitchen. Soon she engaged in trivial
employments. “After a fortnight,” said the old man, “I knocked off the
chains and made her a free woman.” She is at times excited, but not vio-
lently; they are careful of her diet; they keep her very clean; she calls them
“father” and “mother.” Go there now and you will find her “clothed,” and
though not perfectly in her “right mind,” so far restored as to be a safe and
comfortable inmate.
Newburyport. Visited the almshouse in June last; eighty inmates; seven
insane, one idiotic. Commodious and neat house; several of the partially
insane apparently very comfortable; two very improperly situated, namely,
an insane man, not considered incurable, in an out-building, whose room
opened upon what was called “the dead room,” affording in lieu of com-
panionship with the living, a contemplation of corpses! The other subject
 Dix, Memorial to the Legislature of Massachusetts — 121
was a woman in a cellar. I desired to see her; much reluctance was shown.
I pressed the request; the Master of the House stated that she was in the cel-
lar; that she was dangerous to be approached; that “she had lately attacked his
wife”; and was often naked. I persisted: “if you will not go with me, give me
the keys and I will go alone.” Thus importuned, the outer doors were
opened. I descended the stairs from within; a strange, unnatural noise
seemed to proceed from beneath our feet; at the moment I did not much
regard it. My conductor proceeded to remove a padlock while my eye
explored the wide space in quest of the poor woman. All for a moment was
still. But judge my horror and amazement, when a door to a closet beneath
the staircase was opened, revealing in the imperfect light a female apparently
wasted to a skeleton, partially wrapped in blankets, furnished for the nar-
row bed on which she was sitting; her countenance furrowed, not by age,
but suffering, was the image of distress; in that contracted space, unlighted,
unventilated, she poured forth the wailings of despair; mournfully she
extended her arms and appealed to me, “why am I consigned to hell?
dark—dark—I used to pray, I used to read the Bible—I have done no
crime in my heart; I had friends, why have all forsaken me!—my God! my
God! why hast thou forsaken me!” Those groans, those wailings come up
daily, mingling with how many others, a perpetual and sad memorial.
When the good Lord shall require an account of stewardship, what shall all
and each answer!
Perhaps it will be inquired how long, how many days or hours she was
imprisoned in these confined limits? For years! In another part of the cellar
were other small closets, only better, because higher through the entire
length, into one of which she by turns was transferred, so as to afford
opportunity for fresh whitewashing, &c. . . .
Violence and severity do but exasperate the Insane: the only availing
influence is kindness and firmness. It is amazing what these will produce.
How many examples might illustrate this position: I refer to one recently
exhibited in Barre. The town Paupers are disposed of annually to some fam-
ily who, for a stipulated sum agree to take charge of them. One of them, a
young woman, was shown to me well clothed, neat, quiet, and employed at
needle-work. It is possible that this is the same being who, but last year,
was a raving madwoman, exhibiting every degree of violence in action and
speech; a very tigress wrought by fury; caged, chained, beaten, loaded with
injuries, and exhibiting the passions which an iron rule might be expected
122 — Enlightenment, Romanticism, and Reform
to stimulate and sustain. It is the same person; another family hold her in
charge who better understand human nature and human influences; she is
no longer chained, caged, and beaten; but if excited, a pair of mittens drawn
over the hands secures from mischief. Where will she be next year, after the
annual sale?
. . . I may here remark that severe measures, in enforcing rule, have in
many places been openly revealed. I have not seen chastisement adminis-
tered by stripes, and in but few instances have I seen the rods and whips, but
I have seen blows inflicted, both passionately and repeatedly.
I have been asked if I have investigated the causes of insanity? I have
not; but I have been told that this most calamitous overthrow of reason,
often is the result of a life of sin; it is sometimes, but rarely added, they
must take the consequences; they deserve no better care! Shall man be
more just than God; he who causes his sun, and refreshing rains, and life-
giving influence, to fall alike on the good and the evil? Is not the total wreck
of reason, a state of distraction, and the loss of all that makes life cherished
a retribution, sufficiently heavy, without adding to consequences so
appalling, every indignity that can bring still lower the wretched sufferer?
Have pity upon those who, while they were supposed to lie hid in secret
sins, “have been scattered under a dark veil of forgetfulness; over whom is
spread a heavy night, and who unto themselves are more grievous than the
darkness.”
. . . We need an Asylum for this class, the incurable, where conflicting
duties shall not admit of such examples of privations and misery.
One is continually amazed as the tenacity of life in these persons. In
conditions that wring the heart to behold, it is hard to comprehend that
days rather than years should not conclude the measure of their griefs and
miseries. Picture her condition! place yourselves in that dreary cage, remote
from the inhabited dwelling, alone by day and night, without fire, without
clothes, except when remembered; without object or employment; weeks and
months passing on in drear succession, not a blank, but with keen life to
suffering; with kindred, but deserted by them; and you shall not lose the
memory of that time when they loved you, and you in turn loved them, but
now no act or voice of kindness makes sunshine in the heart. Has fancy
realized this to you? It may be the state of some of those you cherish! Who
shall be sure his own hearth-stone shall not be desolate? nay, who shall say
his own mountain stands strong, his lamp of reason shall not go out in
 The M’Naughten Rules — 123
darkness! To show how many has this become a heart-rending reality! If for
selfish ends only, should not effectual Legislation here interpose?
. . . Men of Massachusetts, I beg, I implore, I demand, pity and protec-
tion, for these of my suffering, outraged sex!—Fathers, Husbands, Broth-
ers, I would supplicate you for this boon—but what do I say? I dishonor
you, divest you at once of christianity and humanity—does this appeal
imply distrust. If it comes burthened with a doubt of your righteousness in
this Legislation, then blot it out; while I declare confidence in your honor,
not less than your humanity. Here you will put away the cold, calculated
spirit of selfishness and self-seeking; lay off the armor of local strife and
political opposition; here and now, for once, forgetful of the earthly and per-
ishable, come up to these halls and consecrate them with one heart and one
mind to works of righteousness and just judgment. Become the benefactors
of your race, the just guardians of the solemn rights you hold in trust. Raise
up the fallen; succor the desolate; restore the outcast; defend the helpless;
and for your eternal and great reward, receive the benediction . . . “Well
done, good and faithful servants, become rulers over many things!”

From Dorothea Dix, Memorial (Boston: Munroe & Francis, 1843), 3–9, 12, 17–18,
20–21, 24–25.

The M’Naughten Rules

(1843)

Up until the early nineteenth century, British and American courts

had no universally accepted standard for defining mental incompe-
tence in criminal cases. In general, judges tended to focus on the
accused’s intellectual capacity for understanding right and wrong.
The growing emphasis in psychiatry on impairments of emotion
and will, however, seemed to challenge this more or less cognitive
notion of insanity.
Daniel M’Naughten (1813–1865) was a Scottish craftsman,
active in the early workers’ movement in Great Britain. On 20
124 — Enlightenment, Romanticism, and Reform
January 1843, believing that conservatives were intent on murder-
ing him, M’Naughten set out to stalk and kill the sitting prime min-
ister, Robert Peel. Mistaking Peel’s secretary Edward Drummond
for the government leader, M’Naughten shot Drummond with a
pistol at point-blank range. Drummond later died. At his trial in
March, M’Naughten pleaded not guilty, his legal counsel enlisting
the expert testimony of physicians, who argued that M’Naughten
suffered from a “moral insanity” in the form of monomania. The
strategy succeeded, and M’Naughten was found not guilty by rea-
son of insanity and confined to an asylum for the rest of his life.
Queen Victoria, displeased with the verdict, asked the House of
Lords to review the decision with a panel of judges. In June 1843,
the House of Lords demanded that the judges answer several
abstract questions involving issues raised by the case. The judges’
responses have since become known as the M’Naughten Rules, and
they have served as the basis for determining legal insanity through-
out many parts of England and the United States to this very day.

Notwithstanding a party accused did an act, which was in itself criminal,

under the influence of insane delusion, with a view of redressing or reveng-
ing some supposed grievance or injury, or of producing some public bene-
fit, he is nevertheless punishable if he knew at the time that he was acting
contrary to law.
That if the accused was conscious that the act was one which he ought
not to do; and if the act was at the same time contrary to law, he is pun-
ishable. In all cases of this kind the jurors ought to be told that every man
is presumed to be sane, and to possess a sufficient degree of reason to be
responsible for his crimes, until the contrary be proved to their satisfaction:
and that to establish a defence on the ground of insanity, it must be clearly
proved that at the time of commiting the act the party accused was labour-
ing under such a defect of reason, from disease of the mind, as not to know
the nature and quality of the act he was doing, or as not to know that what
he was doing was wrong.
That a party labouring under a partial delusion must be considered in
the same situation, as to responsibility, as if the facts, in respect to which
the delusion exists, were real.
 The M’Naughten Rules — 125
That where an accused person is supposed to be insane, a medical man,
who has been present in Court and heard the evidence, may be asked, as a
matter of science, whether the facts stated by the witnesses, supposing
them to be true, show a state of mind incapable of distinguishing between
right and wrong.
The prisoner had been indicted for that he, on the 20th day of January
1843, at the parish of Saint Martin in the Fields, in the county of Middle-
sex, and within the jurisdiction of the Central Criminal Court, in and upon
one Edward Drummond, feloniously, wilfully, and of his malice afore-
thought, did make an assault; and that the said Daniel M’Naghten,* a cer-
tain pistol of the value of 20s, loaded and charged with gunpowder and a
leaden bullet (which pistol he in his right hand had and held), to, against
and upon the said Edward Drummond, feloniously, wilfully, and of his mal-
ice aforethought, did shoot and discharge; and that the said Daniel
M’Naghten, with the leaden bullet aforesaid, out of the pistol aforesaid, by
force of the gunpowder, etc., the said Edward Drummond, in and upon the
back of him the said Edward Drummond, feloniously, etc. did strike, pene-
trate and wound, giving to the said Edward Drummond, in and upon the
back of the said Edward Drummond, one mortal wound, etc., of which
mortal wound the said E. Drummond languished until the 25th of April
and then died; and that by the means aforesaid, he the prisoner did kill and
murder the said Edward Drummond. The prisoner pleaded Not guilty.
Evidence having been given of the fact of the shooting of Mr. Drum-
mond, and of his death in consequence thereof, witnesses were called on
the part of the prisoner, to prove that he was not, at the time of commit-
ting the act, in a sound state of mind. The medical evidence was in sub-
stance this: That persons of otherwise sound mind, might be affected by
morbid delusions: that the prisoner was in that condition: that a person so
labouring under a morbid delusion, might have a moral perception of right
and wrong, but that in the case of the prisoner it was a delusion which car-
ried him away beyond the power of his own control, and left him no such
perception; and that he was not capable of exercising any control over acts
which had connexion with his delusion: that it was of the nature of the dis-
ease with which the prisoner was affected, to go on gradually until it had

*Editor’s note: M’Naughten’s surname was spelled a variety of ways in public

documents.
126 — Enlightenment, Romanticism, and Reform
reached a climax, when it burst forth with irresistible intensity: that a man
might go on for years quietly, though at the same time under its influence,
but would all at once break out into the most extravagant and violent
paroxysms.
Some of the witnesses who gave this evidence, had previously exam-
ined the prisoner: others had never seen him till he appeared in Court,
and they formed their opinions on hearing the evidence given by the
other witnesses.
Lord Chief Justice Tindal (in his charge): The question to be deter-
mined is, whether at the time the act in question was committed, the pris-
oner had or had not the use of his understanding, so as to know that he was
doing a wrong or wicked act. If the jurors should be of opinion that the pris-
oner was not sensible, at the time he committed it, that he was violating the
laws both of God and man, then he would be entitled to a verdict in his
favour: but if, on the contrary, they were of opinion that when he commit-
ted the act he was in a sound state of mind, then their verdict must be
against him.
Verdict, Not guilty, on the ground of insanity.
This verdict, and the question of the nature and extent of the unsound-
ness of mind which would excuse the commission of a felony of this sort,
having been made the subject of debate in the House of Lords (the 6th and
13th March 1843; see Hansard’s Debates, vol. 67, pp. 288, 714), it was
determined to take the opinion of the Judges on the law governing such
cases. Accordingly, on the 26th of May, all the Judges attended their Lord-
ships, but no questions were then put.
On the nineteenth of June, the Judges again attended the House of
Lords; when (no argument having been had) the following questions of law
were propounded to them:
1st. What is the law respecting alleged crimes committed by persons
afflicted with insane delusion, in respect of one or more particular subjects
or persons: as, for instance, where at the time of the commission of the
alleged crime, the accused knew he was acting contrary to law, but did the
act complained of with a view, under the influence of insane delusion, of
redressing or revenging some supposed grievance or injury, or of producing
some supposed public benefit?
2d. What are the proper questions to be submitted to the jury, when a
person alleged to be afflicted with insane delusion respecting one or more
 The M’Naughten Rules — 127
particular subjects or persons, is charged with the commission of a crime
(murder, for example), and insanity is set up as a defence?
3d. In what terms ought the question to be left to the jury, as to the
prisoner’s state of mind at the time when the act was committed?
4th. If a person under an insane delusion, as to existing facts, commits
an offence in consequence thereof, is he thereby excused?
5th. Can a medical man conversant with the disease of insanity, who
never saw the prisoner previously to the trial, but who was present during
the whole trial and the examination of all the witnesses, be asked his opin-
ion as to the state of the prisoner’s mind at the time of the commission of
the alleged crime, or his opinion whether the prisoner was conscious at the
time of doing the act, that he was acting contrary to law, or whether he was
labouring under any and what delusion at the time?
Mr. Justice Maule: I feel great difficulty in answering the questions put
by your Lordships on this occasion: First, because they do not appear to
arise out of and are not put with reference to a particular case, or for a par-
ticular purpose, which might explain or limit the generality of their terms,
so that full answers to them ought to be applicable to every possible state
of facts, not inconsistent with those assumed in the questions: this diffi-
culty is the greater, from the practical experience both of the bar and the
Court being confined to questions arising out of the facts of particular
cases: Secondly, because I have heard no argument at your Lordships’ bar
or elsewhere, on the subject of these questions; the want of which I feel the
more, the greater are the number and extent of questions which might be
raised in argument: and Thirdly, from a fear of which I cannot divest
myself, that as these questions relate to matters of criminal law of great
importance and frequent occurrence, the answers to them by the Judges
may embarrass the administration of justice, when they are cited in crimi-
nal trials. For these reasons I should have been glad if my learned brethren
would have joined me in praying your Lordships to excuse us from answer-
ing these questions; but as I do not think they ought to induce me to ask
that indulgence for myself individually, I shall proceed to give such answers
as I can, after the very short time which I have had to consider the ques-
tions, and under the difficulties I have mentioned; fearing that my answers
may be as little satisfactory to others as they are to myself.
The first question, as I understand it, is, in effect, What is the law
respecting the alleged crime, when at the time of the commission of it, the
128 — Enlightenment, Romanticism, and Reform
accused knew he was acting contrary to the law, but did the act with a view,
under the influence of insane delusion, of redressing or revenging some
supposed grievance or injury, or of producing some supposed public bene-
fit? If I were to understand this question according to the strict meaning of
its terms, it would require, in order to answer it, a solution of all questions
of law which could arise on the circumstances stated in the question, either
by explicitly stating and answering such questions, or by stating some prin-
ciples or rules which would suffice for their solution. I am quite unable to
do so, and, indeed, doubt whether it be possible to be done; and therefore
request to be permitted to answer the question only so far as it compre-
hends the question, whether a person, circumstanced as stated in the ques-
tion, is, for that reason only, to be found not guilty of a crime respecting
which the question of his guilt has been duly raised in a criminal proceed-
ing, and I am of opinion that he is not. There is no law, that I am aware of,
that makes persons in the state described in the question not responsible
for their criminal acts. To render a person irresponsible for crime on
account of unsoundness of mind, the unsoundness should, according to
the law as it has long been understood and held, be such as rendered him
incapable of knowing right from wrong. The terms used in the question
cannot be said (with reference only to the usage of language) to be equiva-
lent to a description of this kind and degree of unsoundness of mind. If the
state described in the question be one which involves or is necessarily con-
nected with such an unsoundness, this is not a matter of law but of physi-
ology, and not of that obvious and familiar kind as to be inferred without
proof.
Second, the questions necessarily to be submitted to the jury, are those
questions of fact, which are raised on the record. In a criminal trial, the
question commonly is, whether the accused be guilty or not guilty: but, in
order to assist the jury in coming to a right conclusion on this necessary
and ultimate question, it is usual and proper to submit such subordinate or
intermediate questions, as the course which the trial has taken may have
made it convenient to direct their attention to. What those questions are,
and the manner of submitting them, is a matter of discretion for the Judge:
a discretion to be guided, by a consideration of all the circumstances attend-
ing the inquiry. In performing this duty, it is sometimes necessary or con-
venient to inform the jury as to the law; and if, on a trial such as is
suggested in the question, he should have occasion to state what kind and
 The M’Naughten Rules — 129
degree of insanity would amount to a defence, it should be stated con-
formably to what I have mentioned in my answer to the first question, as
being, in my opinion, the law on this subject.
Third, there are no terms which the Judge is by law required to use.
They should not be inconsistent with the law as above stated, but should
be such as, in the discretion of the Judge, are proper to assist the jury in
coming to a right conclusion as to the guilt of the accused.
Fourth, the answer which I have given to the first question, is applic-
able to this.
Fifth, whether a question can be asked depends not merely on the ques-
tions of fact raised on the record, but on the course of the cause at the time
it is proposed to ask it; and the state of an inquiry as to the guilt of a per-
son charged with a crime, and defended on the ground of insanity, may be
such, that such a question as either of those suggested, is proper to be asked
and answered, though the witness has never seen the person before the
trial, and though he has merely been present and heard the witnesses: these
circumstances, of his never having seen the person before, and of his hav-
ing merely been present at the trial, not being necessarily sufficient, as it
seems to me, to exclude the lawfulness of a question which is otherwise
lawful; though I will not say that an inquiry might not be in such a state,
as that these circumstances should have such an effect.
Supposing there is nothing else in the state of the trial to make the
questions suggested proper to be asked and answered, except that the wit-
ness had been present and heard the evidence; it is to be considered
whether that is enough to sustain the question. In principle it is open to
this objection, that as the opinion of the witness is founded on those con-
clusions of fact which he forms from the evidence, and as it does not appear
what those conclusions are, it may be that the evidence he gives is on such
an assumption of facts, as makes it irrelevant to the inquiry. But such ques-
tions have been very frequently asked, and the evidence to which they are
directed has been given, and has never, that I am aware of, been success-
fully objected to. Evidence, most clearly open to this objection, and on the
admission of which the event of a most important trial probably turned,
was received in the case of The Queen v. M’Naghten, tried at the Central
Criminal Court in March last, before the Lord Chief Justice, Mr. Justice
Williams, and Mr. Justice Coleridge, in which counsel of the highest emi-
nence were engaged on both sides; and I think the course and practice of
130 — Enlightenment, Romanticism, and Reform
receiving such evidence, confirmed by the very high authority of these
Judges, who not only received it, but left it, as I understand, to the jury,
without any remark derogating from its weight, ought to be held to warrant
its reception, notwithstanding the objection in principle to which it may be
open. In cases even where the course of practice in criminal law has been
unfavourable to parties accused, and entirely contrary to the most obvious
principles of justice and humanity, as well as those of law, it has been held
that such practice constituted the law, and could not be altered without the
authority of Parliament.
Lord Chief Justice Tindal: My Lords, Her Majesty’s Judges (with the
exception of Mr. Justice Maule, who has stated his opinion to your Lord-
ships), in answering the questions proposed to them by your Lordships’
House, think it right, in the first place, to state that they have forborne
entering into any particular discussion upon these questions, from the
extreme and almost insuperable difficulty of applying those answers to
cases in which the facts are not brought judicially before them. The facts
of each particular case must of necessity present themselves with endless
variety, and with every shade of difference in each case; and as it is their
duty to declare the law upon each particular case, on facts proved before
them, and after hearing argument of counsel thereon, they deem it at
once impracticable, and at the same time dangerous to the administration
of justice, if it were practicable, to attempt to make minute applications of
the principles involved in the answers given by them to your Lordships’
questions.
They have therefore confined their answers to the statement of that
which they hold to be the law upon the abstract questions proposed by
your Lordships; and as they deem it unnecessary, in this peculiar case, to
deliver their opinions seriatim, and as all concur in the same opinion, they
desire me to express such their unanimous opinion to your Lordships.
The first question proposed by your Lordships is this: “What is the law
respecting alleged crimes committed by persons afflicted with insane delu-
sion in respect of one or more particular subjects or persons: as, for
instance, where at the time of the commission of the alleged crime the
accused knew he was acting contrary to law, but did the act complained of
with a view, under the influence of insane delusion, of redressing or reveng-
ing some supposed grievance or injury, or of producing some supposed pub-
lic benefit?”
 The M’Naughten Rules — 131
In answer to which question, assuming that your Lordships’ inquiries
are confined to those persons who, labour under such partial delusions
only, and are not in other respects insane, we are of opinion that, notwith-
standing the party accused did the act complained of with a view, under the
influence of insane delusion, of redressing or revenging some supposed
grievance or injury, or of producing some public benefit, he is nevertheless
punishable according to the nature of the crime committed, if he knew at
the time of committing such crime that he was acting contrary to law; by
which expression we understand your Lordships to mean the law of the
land.
Your Lordships are pleased to inquire of us, secondly, “What are the
proper questions to be submitted to the jury, where a person alleged to
be afflicted with insane delusion respecting one or more particular sub-
jects or persons, is charged with the commission of a crime (murder, for
example), and insanity is set up as a defence?” And, thirdly, “In what
terms ought the question to be left to the jury as to the prisoner’s state
of mind at the time when the act was committed?” And as these two
questions appear to us to be more conveniently answered together, we
have to submit our opinion to be, that the jurors ought to be told in all
cases that every man is to be presumed to be sane, and to possess a suffi-
cient degree of reason to be responsible for his crimes, until the contrary
be proved to their satisfaction; and that to establish a defence on the
ground of insanity, it must be clearly proved that, at the time of the com-
mitting of the act, the party accused was labouring under such a defect of
reason, from disease of the mind, as not to know the nature and quality
of the act he was doing; or, if he did know it, that he did not know he was
doing what was wrong. The mode of putting the latter part of the ques-
tion to the jury on these occasions has generally been, whether the
accused at the time of doing the act knew the difference between, right
and wrong: which mode, though rarely; if ever, leading to any mistake
with the jury, is not, as we conceive, so accurate when put generally and
in the abstract, as when put with reference to the party’s knowledge of
right and wrong in respect to the very act with which he is charged. If the
question were to be put as to the knowledge of the accused solely and
exclusively with reference to the law of the land, it might tend to con-
found the jury, by inducing them to believe that an actual knowledge of
the law of the land was essential in order to lead to a conviction; whereas
132 — Enlightenment, Romanticism, and Reform
the law is administered upon the principle that every one must be taken
conclusively to know it, without proof that he does know it. If the
accused was conscious that the act was one which he ought not to do,
and if that act was at the same time contrary to the law of the land, he is
punishable; and the usual course therefore has been to leave the question
to the jury, whether the party accused had a sufficient degree of reason to
know that he was doing an act that was wrong: and this course we think
is correct, accompanied with such observations and explanations as the
circumstances of each particular case may require.
The fourth question which your Lordships have proposed to us is this:
“If a person under an insane delusion as to existing facts, commits an
offence in consequence thereof, is he thereby excused?” To which question
the answer must of course depend on the nature of the delusion: but, mak-
ing the same assumption as we did before, namely, that he labours under
such partial delusion only, and is not in other respects insane, we think he
must be considered in the same situation as to responsibility as if the facts
with respect to which the delusion exists were real. For example, if under
the influence of his delusion he supposes another man to be in the act of
attempting to take away his life, and he kills that man, as he supposes, in
self-defence, he would be exempt from punishment. If his delusion was that
the deceased had inflicted a serious injury to his character and fortune, and
he killed him in revenge for such supposed injury, he would be liable to
punishment.
The question lastly proposed by your Lordships is: “Can a medical man
conversant with the disease of insanity, who never saw the prisoner previ-
ously to the trial, but who was present during the whole trial and the exam-
ination of all the witnesses, be asked his opinion as to the state of the
prisoner’s mind at the time of the commission of the alleged crime, or his
opinion whether the prisoner was conscious at the time of doing the act
that he was acting contrary to law, or whether he was labouring under any
and what delusion at the time?” In answer thereto, we state to your Lord-
ships, that we think the medical man, under the circumstances supposed,
cannot in strictness be asked his opinion in the terms above stated, because
each of those questions involves the determination of the truth of the facts
deposed to, which it is for the jury to decide, and the questions are not mere
questions upon a matter of science, in which case such evidence is admis-
sible. But where the facts are admitted or not disputed, and the question
 The M’Naughten Rules — 133
becomes substantially one of science only, it may be convenient to allow the
question to be put in that general form, though the same cannot be insisted
on as a matter of right.

From 8ER 718, [1843] UKHL J16 British and Irish Legal Information Institute,
United Kingdom House of Lords Decisions, http://www.bailii.org/uk/cases/
UKHL/1843/J16.html.
 The Asylum

The Opal: A Monthly Periodical of

the State Lunatic Asylum, Devoted
to Usefulness, Edited by the Patients
of the Utica State Lunatic Asylum
(1850–1860)

Beginning in November 1850, the patients at the Utica State

Lunatic Asylum in upstate New York began writing, editing, and
publishing a monthly newsletter, the Opal. Dedicating their effort
to “usefulness,” patients and ex-patients were given remarkable
license to pen essays, poems, and reflections. Proceeds from sub-
scriptions were used to stock the patient library collection. The
monthly was eventually discontinued in 1860. Since the Opal was
directed at readers both inside and outside the asylum, its stories
and articles provide a glimpse into not only how patients viewed
insanity and themselves, but also how they perceived staff, treat-
ment, and the outside world.

Truthfulness with the Insane (1852)

The most numerous by far of all cases of conscience brought constantly

into the casuistical court are those which relate to the duties of Truth. “Are

134
 The Opal — 135

William Hogarth (1697–1764), Scene in Bedlam (1735), from A Rake’s Progress

(plate 8). Bedlam, or Bethlem (medieval variations of “Bethlehem”), Hospital
in London began specializing in the care of the insane in 1403. Well into the
nineteenth century, it was possible for locals and travelers to tour madhouses,
much like the two women portrayed here. Etching and engraving on paper.
Tate Gallery, London, Great Britain. © Tate, London/Art Resource, NY.

we bound to speak the truth at all times?” Who has not, at some periods
of his experience, been perplexed with this question, and longed to know in
what way to resolve it. . . .
Now, we venture to say, there is no one case of conscience more com-
monly deemed easy of solution, than that which has regard to the duty of
truthfulness with the sick and the insane. We put both of these classes of per-
sons together, because, for our purpose, the question is substantially the
same with respect to both. An insane man is a man under the influence,
commonly, of some bodily weakness or disease, and it is a very common
effect of bodily sickness to produce, in greater or lesser degree, mental
derangement.
We say there is no case of conscience more easily solved, according to
the popular estimation, than this one with reference to truth-telling
136 — The Asylum
towards the sick and insane. In fact, it has become hardly a question at all,
with the great majority. Leaving the insane out of the question, who does
not know how common is the practice of equivocation and deceit towards
the sick? Who does not know how often physicians lead the way in this
sort of dealing? It is not an unfrequent thing—we speak from our own
observation—that physicians conduct themselves in this particular, as if
they were absolved from all obligation to the rules of veracity by virtue of
their profession. How often does it occur that they flatter their patients
with speedy, or, at least, ultimate recovery, when they have already judged
the case to be hopeless, and the sufferer is already lying upon the verge of
the grave. We have known the sick, and the family that watched around
the bed-side, kept in utter ignorance of the true state of the progress of the
disease, at the same time that the patient was rapidly sinking into the arms
of death, and the physician who had spoken only words of assurance and
hope in his ear, was telling to all without the household that recovery was
impossible! We trust that such a course is not characteristic of the pro-
fession in general. We are glad to know that by the best medical authori-
ties, and by our most scientific and distinguished practitioners, it is
entirely disapproved. We hesitate not, to brand such conduct on the part
of the appointed guardians of the sick-bed, to be as uncalled for and cruel
as it is treacherous and wicked.
There are many who will assent to the justness of the views stated
above, who will very likely dissent from us when we come to speak of the
expediency and duty of truthfulness towards the insane. There are multitudes
who, doubtless, consider it neither expedient nor a duty to observe strict
veracity with this unfortunate class of persons. It is, we believe, a general
impression that those who have to do with the insane in our Asylums are
governed by no rules upon the subject, unless it be the rule of employing
both truth and falsehood, according as one or the other shall be best suited
to the particular exigency. This, in fact, was our own impression, until our
residence and entrance as a patient within the walls of the N.Y. State Asy-
lum gave us an opportunity to ascertain the policy actually adopted. . . . It
will, perhaps, be presuming too much, but we will venture one or two sug-
gestions upon this subject. . . .
First then, Insanity is but another word for delusion, the delusion of
falsehood, and falsehood manifestly, therefore, is not the proper cure for a
disease of which it is, in itself, the essence. The thing which needs to be
 The Opal — 137
expelled from the mind of an insane person, before it can be recovered to
soundness, is the falsehood under which it labors, and how this can be
best done by injecting new falsehood into the mind, we may well be at a
loss to know. If a child has been fed upon sweetmeats until it has become
pale and thin like a skeleton, is it best, in order to its recovery, to continue
the sweetmeats or to endeavor to neutralize and overcome their already
hurtful effect by a new and nourishing diet? There is but one answer to
this question, an answer suggested by the very nature of the case, as we
should say. Now as with the emaciated body, so with the deranged mind.
No mind can be in a health condition that feeds upon falsehood. It must,
of course, be diseased and hastening to decay. What it needs is something
different and opposite to that which it has fed upon, and that something is
truth.
It is certain, furthermore, that the insane are more or less susceptible
to all influences exerted in consistency with the requirements of veracity. It
no uncommon thing in the experience of those who have charge of institu-
tions for the insane to find the delusion of their patients giving way before
a continual representation of the truth. Nor is it unfrequent that the recov-
ered patient is able to call to mind, how the truthful declarations of his
physician first broke in upon his delusions with persuasive power, and how
from this source the first ray of light shone upon the brooding darkness.
We can speak from experience, how much it contributed to the rest of a
mind tossed upon the billows of phrenzy and despair, when we had gained
the conviction that those who were placed in charge of us were men in
whose slightest utterance we could have confidence; men who made it a
sacred principle not to deceive their patients in any particular. There is a
certain point of recovery when the disordered mind seeks to discriminate
between that which is true and that which is false in its condition. It has
delusions which it would gladly rid itself of, if it might dare to do so; but it
has others, equally hurtful, to which it would as gladly hold fast. Then also,
there are some of which are pleasant, and others, it may be disagreeable to
contemplate; but now, as he finds his delusions beginning to dissipate, what
shall he do with these? Ought he to retain his confidence in them while he
dismisses it in the others? In such circumstances what can be more grate-
ful to the tempest-tost soul than to have at hand a faithful counsellor,
whose every word is truth, and who may be relied on to guide his trembling
steps through the maze he is treading.
138 — The Asylum
Editor’s Table (1852)

Considerable anxiety is sometimes expressed by persons who derive a mor-

bid satisfaction from looking on scenes of human misery, as to the propri-
ety, safety, &c., of their visiting the Asylum. This diseased state of the
sentiments is most incident to those who have been badly educated, and
who, especially, have not been taught to follow up feeling by the corre-
sponding actions. They are mightily stirred by a story of distress, but never
think of an effort to relieve it. The natural tie between emotion and conduct
has suffered a violent disruption.—We do not like to see such people pass-
ing through the halls. The authoress of the following letter belongs to the
class we have been describing, and a decent respect for her sex demands
that we should not pass it by unnoticed.

To the Editor of The Opal:

Sir,— My father is a citizen of the State of New York, and a voter
in regular standing, and he has told me that by reason of these things
he and his family have free admission to the Asylum. As I have not
much to do at home, (mother and the help doing all the work), I pro-
posed a few days ago that we should have a good sleigh-ride and fetch
up at the Asylum. We were a merry party. When we got up on the
big stoop and among the stone pillars, we were surprised to have a
man say to us, that “it was past the hour for visitors.” We were indig-
nant of course, and told him that we had come to go through the Asy-
lum, and not to learn the time of day. He said that he would have to
speak to some one; and soon a man came to us, (a mighty handsome
one by the way) and fixing a great searching black eye upon us, said
to us that we might go through; but he scared us all by cautioning us
with a tone and look, which I shall never forget, to bear in mind that
we were in a Hospital for the Insane. So we went around. Every thing
was as clean as clean can be. (I hope mother wont go there; for she is
forever dinging at me about dirt in my room): We were all disap-
pointed. For all we could see, the patients look and act like other peo-
ple. We asked our guide, who was civil enough, if he wouldn’t take us
where we could see something. He politely bowed us away to the
sleigh.
Now, Sir, if this is all that one can see in your place, I beg leave to
tell you that I shall not visit it again, and shall dissuade all my friends
from doing so.
 The Opal — 139
This is all at present from
Yours to command,
Araminta C. Stubbs
P.S.—Pray, is not the young man who went round with us a bit of a
wag, or is he one of the patients? A.C. S.

Miss Araminta C. complains that “for all she could see, the patients
look and act like other people.” Ah—could she look into the inner soul of
those whose apparent composure has so disappointed her sickly and vulgar
anticipations! Could she see the heart aching with a grief which will not and
cannot be comforted—or withered by long and solitary indulgence in
thoughts of the neglect or scorn of the world, which, whether real or imag-
inary, cannot be removed by the sympathising tones nor cheering smiles of
that love which always soothes and animates a mind in trouble—or torn
and racked by passions which are always contending with each other, and,
having no reality for their object, may never give any outward manifestation
of the agonizing tumult which reigns within!
But Araminta complains, that she was not taken where she could “see
something.”—What does she mean by something? Is it slam-bang, kick,
rear up, smash windows, make fun, and yell? Such things are to be seen out-
side of, as well as within the Asylum; but however entertaining they might
be to the lady, the performance of them might hazard her safety. There are,
we own, many queer cases amongst us, whose idiosyncrasies, while they
are very funny, never endanger the safety of the most timid or the most
pure. There is especially one little fellow whose ideas run incessantly on
osculation. An uncontrollable desire to kiss every thing he sees is his fail-
ing. And the dreadful looks of the objects he sometimes selects for this pas-
time are the chief grounds for declaring him insane. . . .

Editor’s Table (1855)

“An Hour with the Insane,” says the courteous editor of the N.Y. Commer-
cial Advertiser, “we spent the other day.” Not that the editor was really here,
in propria persona, but in perusing the pages of the opal, his mind and kind
sympathies were here. Well, others, we trust, have in like manner, “spent
an instructive hour,” and others, still, might find the perusal of its un-
pretending pages instructive and pleasing, were they to receive it. The
140 — The Asylum
fragrance of the rose is not diminished by its seclusion from the embel-
lished floral bower—nor are the thoughts of truth and beauty which find
utterance here, less fraught with the aroma of wisdom because they
emanate from the seclusive quite of Asylumia.
If not our gratitude, certainly our pride is awakened by the fraternal
etiquette of the Advertiser—somewhat critical though it is, since by hav-
ing nearly now reached its half century, it deserves, as it surely has, our
need of veneration—and the manner of its allusion to our opalescent
gems is in nowise unappreciated. But we deem it proper to say, here, that
its articles are all written by patients, and under no other “supervision”
or restraint than their own genii. The beloved and honored Superinten-
dent, nor either of his estimable Assistants interpose any control or
direction in the productions of the brains or pens of the contributors to
the opal—that is, they do not advise or supervise in the matter, farther
than to express their decisions that such and such individuals, thus
desiring—and many are here, somehow seized with author-mania, who
before never thought of the thing—may be furnished with writing mate-
rials and opportunities to “improve their gifts.” Every one thus fur-
nished, writes “what is written;” and as written, each article appears,
with such alterations only, as the principal editor, or the printer, might
properly make in similar cases, regarding punctuation, &c. And when we
reflect that many of our most approved articles are written by patients
occupying halls where there is little to superinduce that elasticity of
mind, and that gaiety of feeling indicated by their compositions—but
where, on the contrary, they are often unavoidably subjected to annoy-
ances from insane singing, talking, laughing, weeping, walking, etc, etc.—
scenes ever to be found among a company of insane persons—we think
we have reason to feel a degree of satisfaction with, if not literary pride
of our productions. And what encouragement doth this one thought of
itself afford the Superintendent and his Assistants, that they do not
“labor in vain,” in a most humane and important department of society,
while laboring to restore their unfortunate fellow-beings to health, use-
fulness and happiness.
And what higher incentive can be presented to the enlightened legisla-
tor or to the statesman, in favor of a liberal appropriation of the public funds
for supplying the Institution with all needful facilities for the care and
restoration to active usefulness the men and women who, for various rea-
 The Opal — 141
sons, it becomes necessary, for a time, to isolate from the associations and
responsibilities of life at large, in the halls of the Asylum?

Views of Insanity by an Ex-patient (1859)

As far as any personal experience goes, we are rather at a loss to convey to

the mind of the sane reader a definite idea of insanity. We were going to say
we never had a spectral vision; but a perhaps Quixotic desire to stick to the
truth, leads us to record the following incident: when a youngster we once
fell asleep on the kitchen floor: being suddenly aroused to consciousness,
we for but an instant of time—hardly that, fancied we saw a gray cat in the
very act of falling upon us: this was our first and last apparition. During a
period antecedent to the last ten years our physical frame was subject to
some disturbances; therefore in giving any opinion as to the essence of
insanity—excepting what we make inferentially from witnessing or hearing
of diseased mentality in others, we draw upon our memory of what we were
at that period.
Without pretending to a very accurate knowledge of metaphysical or
medical science, our knowledge enables us to make these two classifications
of insanity—diseased will; diseased perception. Under the first class, we are
forced to enroll ourselves; in the second, not at all; yet, ten years ago, we
might have properly been under that other classification.
Previous to the time in question, we dreamed (perhaps in a secondary
sense the observation applied to the day as well as the night): during that
time our slumbers have been dreamless. To this assertion we add the fol-
lowing qualification: we have sometimes awakened from an apparently
unbroken rest and been told that we had talked in our sleep. Nevertheless
we believe that during the period specified, unbroken rest has been the rule,
and dreaming the momentary exception.
Let us without making open war against the dogmas of science, in mak-
ing our classification, record our impression that the first has (in a great meas-
ure) but an existence in the imagination of men—that the proper
nomenclature of moral insanity is wicked will. Acting under the conviction
to a great extent, we state our opinions. Insanity is the stuff that dreams are
made of. We fancy it closely allied to somnambulism. In some tempera-
ments, under severe exertion of the mental and physical powers, the mind
is withdrawn from contact with surrounding objects, while the body
142 — The Asylum
continues mechanically to perform its customary actions—to exemplify
which, a canal-driver, I think, told me that he had, when on foot, following
his horse in the night-time, fallen asleep, yet continuing to follow his horse.
We mention also that after the toil of a summer’s day (during the period
when our physical frame was not what it is now) playing on an instrument
of music, we have fallen asleep and awakened, without, as we believed, dis-
turbing the progress of the music.
Insanity, dreams, clairvoyance, somnambulism, and catalepsy—all, we
have an opinion, are links between the terrestrial and spirit world. This last
is the region or regions where the spirit, disembodied, betakes itself after
death—and, under abnormal conditions, before. In these abnormal states
the mind has gone, partially or wholly. Where a slight degree of exterior
(physical) perception remains, an insane person seems to have his physical
senses, seeing, etc.,—while he is in most respects like one in a fit or catalep-
tic trance. That insanity is but a waking-day-sleep, is gathered not from our
own experience, but that of lunatics with whom we conversed after they
had become sound.

From Opal: A Monthly Periodical of the State Lunatic Asylum, Devoted to Usefulness,
Edited by the Patients of the Utica State Lunatic Asylum (Utica, NY: Utica State Lunatic
Asylum), 1851–1860; excerpts are from the following: 1852, vol. 2, 33–35,
121–122; 1855, vol. 5, 188–189; 1859, vol. 9, 32–33.
 Report of the Limerick District Lunatic Asylum — 143

Limerick District Lunatic Asylum

Report of the Limerick District Lunatic
Asylum for the Year Ending December
31st, 1866
(1867)

Superintendents of asylums were generally obligated to submit an

annual report to those organizations and authorities in charge of
supporting and supervising the facility. These reports provide fairly
detailed information about matters such as the number of admis-
sions and discharges, patient behavior and treatment, staff, and the
status of buildings and grounds. The following is an excerpt from
an annual report submitted by the physician Robert Fitzgerald, res-
ident medical superintendent of the Limerick District Lunatic Asy-
lum in Ireland, to local political and church authorities. What
appear at first glance to be rather mundane statistical tables reveal a
great deal about the kinds of individuals institutionalized, how life
in the asylum was organized, and how administrators categorized
patients and disorders. Note that the abbreviation “Do.” below
stands for “ditto.”
144 — The Asylum
Return of the Number of Patients Admitted,
Discharged, Died, and Escaped within the Year
Males Females TOTAL

Number of patients remaining in

Asylum on 31 December 1865 224 219 443
Do. Patients admitted to 31 Dec 1866 31 39 70

TOTAL 255 258 513

Number Discharged 20 17
Recovered during the year . . .
Do. Improved 4 10
Do. Unimproved 2 3
Do. Escaped 1 0
Do. Deaths 2 9
TOTAL 68

Remaining in Asylum on 31 Dec 1866 226 219 445

Distribution by Counties
City of Limerick 21 31 52
County of Limerick 110 103 213
County of Clare 95 85 180
TOTAL 226 219 445
State as to Probability of Recovery of
those in Asylum on 31 December 1866
Lunatics Probably Curable 49 46 95
Lunatics Probably Incurable 154 149 303
Lunatics, Idiots 9 10 19
Lunatics, Epileptics 14 14 28
TOTAL 226 219 445
Classification of Patients according to
Physician’s Abstract of Cases
Mania—Probably Curable 49 46 95
Do. Do. Incurable 154 149 303
Do. Idiots 9 10 19
Do. Epileptics 14 14 28
TOTAL 226 219 445

Daily Average Number of Patients 443

 Report of the Limerick District Lunatic Asylum — 145
Daily Average Number of Patients Employed
during the Year Ended 31st December, 1866
Male Female

Garden Labour 2 Needle Work 35

Agricultural Labour 30 Knitting 34
Tailoring Work 1 Assisting in Laundry 18
Carpentry 1 Cleaning House 18
Cleaning House 14 Miscellaneous 23
Miscellaneous 8

TOTAL EMPLOYED 56 TOTAL EMPLOYED 128

Work Done by Female Patients

Made: 400 shirts, 240 sheets, 364 chemises, 180 gowns, 162 petticoats,
310 caps, 498 aprons, 89 bed ticks, 124 bolsters, 24 table cloths,
12 bath towels, 13 rollers, 604 pairs of stockings, and 623 pairs
of socks.

Repaired: 500 jackets, 601 pairs of trousers, 276 waist coats, 571 shirts,
244 sheets, 167 blankets, 134 bed ticks, 149 bolsters,
800 gowns, 921 chemises, 621 petticoats, 214 caps,
281 aprons, 10 table cloths, 47 shawls, 3814 pairs of
stockings, and 4124 pairs of socks.
146 — The Asylum
Authority for Admissions
Authority for Admission of Patients, and Number Admitted
during the Year ended 31st December, 1866

Males Females TOTAL

Ordinary cases admitted by order
of the Board 4 7 11
Ordinary cases admitted as urgent
by the Physicians 16 23 39
Dangerous Lunatics, by Warrant
of the Lord Lieutenant 9 6 15
Lunatics charged with offences, by
Warrant of the Lord Lieutenant 2 3 5
TOTAL 31 39 70

Age of Patients
Age of Patients Admitted and Discharged Recovered
during the Year ended 31st December, 1866

Discherged Discharged Discharged

Admitted Admitted Admitted Cured Cured Cured
Male Female TOTAL Male Female TOTAL

Under 10 1 1 2 0 1 1
10–20 17 4 21 0 2 2
20–30 5 8 13 11 8 19
30–40 6 9 15 3 2 5
40–50 0 11 11 4 3 7
50–60 0 5 5 0 1 1
60–70 1 1 2 1 0 1
70 and
upwards 1 0 1 1 0 1
TOTAL 31 39 70 20 17 37
 Report of the Limerick District Lunatic Asylum — 147
Duration of Illness
Duration of Disease previous to Admission in those
Discharged Recovered during the Year ended 31st December, 1866

Males Females TOTAL

Under 1 month 5 3 8
Under 3 months 3 1 4
Under 6 months 2 1 3
Under 9 months 1 1 2
Under 1 year 2 1 3
Under 2 years 1 1 2
Under 3 years 2 2
Under 4 years 2 2
Under 5 years 1 2 3
Under 6 years
Under 8 years
Under 10 years and upwards
Unknown 5 3 8
TOTAL 20 17 37

Length of Stay
Length of Residence in Asylum of those Discharged, Recovered,
and Improved during the Year ended 31st December, 1866

Recovered Recovered Recovered Improved Improved Improved

Male Female TOTAL Male Female TOTAL

Under 2 months 7 2 9 2 1 3
Under 4 months 2 2 4
Under 6 months 2 2 4 1 1
Under 8 months 2 2
Under 12 months 2 6 8 1 3 4
Under 18 months 3 3
Under 2 years 1 2 3 1 1
Under 3 years 3 1 4 1 1
Under 4 years 1 1
Under 5 years 1 1
Under 6 years 1 1
Under 10 years 2 2
TOTAL 20 17 37 5 10 15
148 — The Asylum
Form of Illness (Admittees)
Form of Disease in those Admitted
during the Year ended 31st December, 1866

Male Female TOTAL

Acute Mania 15 20 35
Chronic Mania 13 12 25
Melancholia 1 1
Melancholia Religious 1 2 3
Hereditary 2 3 5
Imbecility 1 1
TOTAL 31 39 70

Form of Illness (Those Remaining)

Form of Disease in those Remaining in Asylum on 31st December, 1866

Male Female TOTAL

Mania Acute and Chronic 137 111 248
Melancholia Religious 39 47 86
Dementia 26 35 61
Monomania 1 1
Imbecility 2 2
Idiocy 9 10 19
Mental Affection 14 14 28
TOTAL 226 219 445

Education
Educational Condition of Patients in Asylum on 31st December, 1866

Male Female TOTAL

Well Educated 21 14 35
Can Read and Write Well 24 28 52
Can Read and Write Indifferently 70 37 107
Can Read Only 48 49 97
Cannot Read or Write 50 81 131
Unknown 13 10 23
TOTAL 226 219 445
 Report of the Limerick District Lunatic Asylum — 149
Marital Status
Social Condition of Patients in Asylum on 31st December, 1866

Male Female TOTAL

Married 35 57 92
Single 187 130 317
Widowers and Widows 4 26 30
Unknown 6 6
TOTAL 226 219 445

Conduct
Classification of Patients in Asylum on 31st December, 1866

Male Female TOTAL

Convalescent 18 9 27
Quiet and Orderly, but Insane 90 73 163
Moderately Tranquil 70 58 128
Noisy and Refractory 48 79 127
Imbecile and Epileptic 14 16 30
Suicidal 4 4
TOTAL 226 219 445
150 — The Asylum
Previous Occupation
Previous Occupation of those in Asylum 31st December, 1866

Male Female TOTAL

Labouring Class 145 44 189
Farming 9 9
Domestic Servants 1 38 39
Clerks 2 2
Shopkeepers 5 4 9
Tailors and Seamstresses 4 5 9
Artisans 2 2
Painters and Glaziers 1 1
Smiths and Workers in Metals 1 1
Masons and Bricklayers 1 1
Carpenters 4 4
Shoemakers 3 3
Hatters 1 1
Factory Workers 1 1
Vicutallers 3 3
Pedlars and Hucksters 1 5 6
Lawyers
Medical Men 2 2
Members of Religious Communities 1 1
Students and Teachers 5 2 7
Soldiers and Pensioners 10 10
Police 2 2
Revenue Officers 2 2
Sailors 1 1
Publicans 1 1
Various Employments

TOTAL 208 98 306

No Occupation or Unknown 18 121 139

TOTAL 226 219 445
 Report of the Limerick District Lunatic Asylum — 151
Causes of Death
Causes of Death during the Year ended 31st December, 1866

Male Female TOTAL

Debility 3 3
Congestion of Brain 2 2
Senile Insanity 1 1 2
Marasmus 1 1
Consumption 1 1
Exhaustion from Epilepsy 1 1 2
TOTAL 2 9 11

Escapes and Escape Attempts

Male Female TOTAL Observations

1 1 Attempted to get away but was caught

inside the walls

1 1 Climbed over the front gate but was

caught immediately

1 1 Attempted to get out through the

Window of his Cell at Night

1 1 Effected his Escape, and his Friends

kept him at home, where he ultimately
became quite well
152 — The Asylum
Supposed Cause of Mental Illness
Supposed Cause of Mental Disease of Patients
in Asylum on 31st December, 1866

Males Females TOTAL

MORAL CAUSES
Poverty and Reverse of Fortune 13 15 28
Grief, Fear, and Anxiety 15 12 27
Love, Jealousy, and Seduction 3 9 12
Domestic Quarrels and Afflictions 2 4 6
Religious Excitement 5 8 13
Study and Mental Excitement 5 3 8
Ill-Treatment 7 7
Pride 1 1
Anger 1 1
Kleptomania 1 1 2
TOTAL MORAL CAUSES 44 61 105
PHYSICAL CAUSES
Intemperance and Irregularity of Life 10 5 15
Cerebral Diseases or Affections 24 21 45
Congenital Idiocy, Etc. 1 1
Febrile Affections 9 9
Effects of Climate and Sunstroke 5 1 6
Bodily Injuries and Disorders 7 7
Abuse of Medicine 2 2
Sedentary Habits 3 3 6
TOTAL PHYSICAL CAUSES 51 40 91
Hereditary 29 28 57
Not Known 102 90 192
TOTAL 226 219 445

Patients under Restraints

Number of Patients Placed under Mechanical Restraint or Seclusion
during the Year ended 31st December, 1866

Male: 0

Female: 14 (all with application of straight Waistcoat)

 Report of the Limerick District Lunatic Asylum — 153

Francisco José de Goya y Lucientes, Lunatic Asylum (ca. 1812–1819). It is

known that Goya visited an asylum around the area of Sargasso. The Sargasso
asylum was part of a hospital complex first built in 1425, and, similar to what
Goya depicts here, patients at the asylum were given tent cloth to wear, vio-
lent patients were kept in cells of wood or limestone, and the floor was cov-
ered with straw. The Sargasso asylum was also noteworthy, however, in that
the inmates put on regular theatrical performances for visitors. Canvas. Real
Academia de Bellas Artes de San Fernando, Madrid, Spain. © Erich Lessing/
Art Resource, NY.

Amusements, Games, Books, &c.

Description of Class of Books and
Amusement and Periodical supplied
Games to Patients Male Female TOTAL

Ball playing Newspapers and

periodicals 24 24
Card playing " 36 36 72
Foot Ball " 50 50
Instrumental Music " 6 6
Music and Dancing " 20 40 60
154 — The Asylum
Patients’ Dietary
Meals Dietary Male Female TOTAL
ORDINARY
Breakfast 7 oz. of Indian Meal and Cutlins
made into Stirabout 155 90 245
12 oz. of Bread for Males
and 8 oz. for Females 71 129 200
1 pint of New Milk 200 120 320
1 pint of Tea 26 99 125
Dinner 12 oz. of Bread, or a 1/4 stone of
Potatoes for Males, 8 oz. of Bread
or 3 lbs. of Potatoes for Females 226 219 445
12 oz. of Beef on Sundays and
Thursdays, 8 oz. on Mondays and
Tuesdays, Ox Head soup on
Saturdays,1 pint of Milk or Coffee
on Wednesays and Fridays 219 213 432
Supper 6 oz. of Bread and 1/2 pint of Milk 226 219 445

Tea 6 6
EXTRA
Breakfast Butter

Dinner Roast Beef and Mutton

HOSPITAL DIET
Porter, Wine, Whiskey, Rice,
and Brandy

From Limerick District Lunatic Asylum, Report of the Limerick District Lunatic Asy-
lum for the Year Ending December 31st, 1866 (Limerick: G. M’Kern & Sons, 1867).
 Report of the Insane Asylums in Bengal, 1867 — 155

Office of Superintendent
Government, Great Britain
Annual Report of the Insane Asylums
in Bengal for the Year 1867
(1868)

Lunatic asylums first appeared in India toward the end of the eigh-
teenth century. What began as an attempt by the East India Com-
pany to build replicas of British asylums on Indian soil was
maintained by the British Crown after it formally established its
rule in 1858. The spread of British asylums throughout India was
justified on the same humanitarian grounds touted earlier by the
likes of Pinel, Esquirol, and Tuke: a colonial obligation to advance
and civilize backward people and institutions.
Since British colonials and authorities considered themselves
superior to their colonized subjects, however, they were unwilling
to compel British nationals to share facilities with native Indians.
Thus, a segregated system was established. Insane Indians were
confined in shabby, public institutions, while their European
counterparts were accommodated in a private asylum, given time to
recuperate, and then returned to their homeland. The following
annual report describes conditions in the public asylum in Patna.

From Surgeon R. F. Hutchinson, M.D. (Superintendent, Patna Lunatic

Asylum) to Surgeon-Major H. M. Macpherson (Secretary, Inspector
General, Medical Department, Lower Provinces). Patna, 1 January 1868

Sir,
I have the honor of submitting the usual Asylum Report for the year
1867, and before entering upon the history of the year, I would draw spe-
cial attention to the following objects of importance: —I. The necessity for
increased accommodation in the Asylum buildings; and
156 — The Asylum
II. The necessity of adapting the present erection to the present
advanced condition of sanitary sciences.
But then the question may be put, in limine, why interfere with either?
the Asylum has jogged on very well in the years that are past; let it do so
equally in the years to come. I think, however, that, with the improvements
I am about to suggest, it will be allowed that matters would progress still
more favourably: that the present rate of sickness and mortality would be
still further diminished, and the general comfort and happiness of the
inmates still better maintained.

I. In May 1866, I reported on the crowded state of the Asylum, and

suggested a mode of relief. It was then overcrowded with 138 patients.
How much more so it is now with 151! The general form and propor-
tions of the Asylum are known to the authorities; so I shall merely
observe that the main building has accommodation for 59 insanes; the
old Civil Jail holds 25; and the female side has 20 cells. Thus the maxi-
mum accommodation is for 104 patients, not taking into consideration
the deep verandahs in both Asylums; but with cell accommodation for
104 patients, we have a total of 151 (113 males and 38 females), or 47
beyond our capacity. Such being the case, (and we are receiving weekly
additions to our strength) some means should be devised for relieving the
pressure before a dire epidemic of cholera sweeps away the surplus, as it
did in 1866.

II. The sanitary improvements necessary. The drainage everywhere is

excellent; but then the building is situated on low ground, which every year
is subject to inundation. Last year the flood was so high that all the drains
were full of backwater, and in 1861 the water was knee-deep at the south
end of the Asylum enclosure. The buildings have not yet recovered from
the effects of last year’s flood; so great was the saturation of the soil, and
the attendant percolation, that the mud floors of the manufacturing sheds,
though a foot above the ground, were puddles, and the foot holes of the
looms were little wells.
The south end of the main building was untenable from the damp
which showed on the walls three feet from the floor; and from having a
northern aspect, and never being reached by the sun, it remains damp and
disagreeable, and unfit for occupation.
 Report of the Insane Asylums in Bengal, 1867 — 157
The sickness might have been considerable, had it not been for the
large quantities of straw which I laid in for the insanes to lie upon.
This evil cannot, of course, be remedied without either raising the
plinth or removing the Asylum bodily to a higher site.
The ventilation of the main block of the Asylum is very defective, and
necessarily so from its shape, which, being that of a large quadrangle run-
ning North and South, can only receive ventilation from the prevailing east-
ern and western winds. Therefore the north and south ranges of cells
rarely, if even, have a breath of air through them, as their doors and win-
dows are all north and south, and they have dead walls to the East and west.
These remarks only apply to the main block, the rest of the Asylum being
admirably ventilated.
To increase the accommodation, and throw open the whole building to
air and sunshine, I would suggest the following alterations, illustrating
them by a plan of the main block. Remove entirely the northern and two
southern rows of cells, and extend to the northern the eastern and western
rows of cells. This extension would exactly compensate for the removals,
and we should thus have two long rows of airy and well ventilated cells,
accommodating 60 patients; and from there being no enclosing walls, there
would be less risk of damp. To the north of the old Dewani Jail, I would
erect two parallel blocks for 40 patients, and in the same manner extend the
female block to the south, allowing accommodation for 40 patients, instead
of 20, as at present. Thus the Asylum would be capable of separately
accommodating 165 patients as follows:

Main block 60 patients

New block 40 patients
Dewani block 25 patients
Female block 40 patients
Total 165 patients
Our present strength being 150.

IV. On the whole, the health of the Asylum has been very good, con-
sidering the risk and discomfort to which the insanes were exposed by the
inundation. The mortality was greater than in the previous year, but then
our numbers were considerably increased; so that the balance is rather in
favor of 1867.
158 — The Asylum
As usual, dysentery and diarrhea carried off the majority of the fatal
cases, there being ten cases of both. Of the nine dysentery cases, not one
was struck down in robust health; four were cases of old age; and the other
five were admitted feeble and emaciated.

V. The conservancy of the Asylum has been carefully attended to, the
dry-earth system being enforced as strictly as possible. I have largely used
McDougall’s Disinfecting Powder, and find it very valuable as a deodoriser.
Until the inundation, the cells were regularly leeped, and are so now, except
in the south end of the male Asylum, where the damp still prevails so
greatly.*

VI. The food of the insane has, on the whole, been good. Tricks have
at times been played with the ata; and to prevent their occurrence, I am anx-
ious to grind our own flour on the premises.†

VII. The clothing has been ample, and of good quality, every part of it
manufactured in the Asylum; and its regular washing has been strictly
attended to. But we have suffered a good deal at the hands of unruly
patients, male and female, whole tháns of dosotee having been torn into
shreds, and numerous blankets consigned to the same fate.‡

VIII. The manufactures are carried on steadily within certain limits.

Insanes will work steadily in the beaten paths; but it is rather difficult to
lead them across country by teaching them arts entirely new for they are by
no means sharp in picking up knowledge, and Return N. 6 [data not
included here] will show that we have not a very large stock of workmen to
draw upon.
However, we manage, in considerable degree, to pay our way, and have
a nice balance to our credit as well.

IX. I have repeatedly had occasion to draw attention to the unsatisfac-

tory, if not illegal, manner in which alleged insanes are sent to the Asylum.

*Editor’s note: Leeping involves washing something with cow dung and water.
†
Editor’s note: Ata is whole wheat flour typically used to make flatbread.
‡
Editor’s note: Thans refers to lengths of cloth; dosotee refers to a particular type of
fabric.
 Report of the Insane Asylums in Bengal, 1867 — 159
In many instances patients have been sent in with merely a scrap of ver-
nacular writing; in others no proper descriptive roll is sent; or if it is, the
information is most meagre, and at times contradictory. Rarely, if ever, is
the strict order requiring personal examination by a Magistrate carried out,
and the consequence is that many a man, reeling about the bazaar intoxi-
cated with ganjah or spirit, finds himself, on coming to his senses, an
inmate of a Lunatic Asylum.*
And this incarceration, however temporary, is by no means a trifling
matter; for let the man ever thereafter religiously eschew ganjah or spirit,
he will never remove the stigma from his name that he once was págul, and
once an inmate of a págul-khána.†
Return No. 4 [data not shown] shows how large a proportion of the
admissions is due to ganjah and bháng.‡ Under the seduction and mad-
dening influence of these poisons, so openly sold and easily procured, many
a career, opening hopefully and prosperously, has terminated in sorrow and
gloom. How bitterly the first, and perhaps only, whiff of that deadly chelum
is lamented; how hopelessly the first, and perhaps solitary, draught of
bháng is deplored! **
We must give the native credit for having feelings like ourselves. We
must allow him a conscience which, though it be frequently dormant, is
still open to the chidings of remorse.
And it is a sad, though interesting, study to watch the workings of the
mind in many a poor patient. The reply with difficulty extracted,—the face
hung down and averted,—the love of silence and solitude,—all indicate the
smitings of conscience and gnawings of remorse, and excite a sincere pity
for the unhappy victim to such seductions.
I have now in the Asylum two or three such cases; one in particular,
where the patient, a Bengali lad, seems overwhelmed with a sense of his dis-
grace and degradation.

X. While noticing one undoubtedly powerful agent in creating insan-

ity, we may fitly examine the pretensions of another supposed to be equally

*Editor’s note: Ganjah is also known as cannabis and hashish.

†
Editor’s note: Págul means “insane” or “mad”; a págul-khána is an insane asylum
or madhouse.
‡
Editor’s note: A preparation from cannabis.
**Editor’s note: Chelum here refers to hashish.
160 — The Asylum
powerful in exciting it. We may try and ascertain whether the word
“lunacy” has any real claims to the derivation assigned to it. Anxious to test
the reality or otherwise of lunar influence on the insane, I carried out dur-
ing the year the following observations, adding to them notes of the pres-
sure, temperature, and humidity of the atmosphere.
As they only extend over a year, they are perhaps not very valuable, but
still the results are interesting; the more so, as they are, I believe, at vari-
ance with prevailing ideas. Thus, extremes of temperature are not neces-
sarily accompanied by maniacal exacerbation, for the greatest heat, 110º F,
was noted on June 4th and September 10th, and the greatest cold, 40º, on
December 15th, and on neither day was any patient excited. Nor are
extremes of pressure; for the Barometer was at its utmost height, 30–33,
on November 23rd at its greatest depression, 29–31, on July 7th, without
any cases of maniacal excitement.
Humidity apparently predisposes to excitement; for on the day of great-
est rain, July 29th (when four inches were gauged), one patient was
attacked; and in July, the month of greatest rain, (when ____ were
gauged),* we had the maximum excitation; in the rainy months of June,
July, August, September, and October we had 45.5 percent of all cases of
excitement.
I should fancy that the mugginess of the rains has as much to say to
these cases as the positive humidity. Now for lunar influence, or lunacy
proper. The annexed Table will show that the lunations had but little influ-
ence on the patients attacked; the greatest number falling to the share of the
new moon, and smallest but one to that of the full moon. And that the full
moon has apparently but little influence will be seen from this Table (B),
which shows that, while forty-nine cases of excitement occurred during the
wax, eighty-nine occurred during the wane of the moon.
On the whole, I think the question is still an open one, to be decided
by further experiment; and I believe that magnetic and electric observations
will yield valuable results. These I hope to commence on the receipt of the
instruments I have sent home for.

XI. I regret that I can only repeat the remarks in my Report for 1865
regarding the Asylum establishment. As a class, the keepers are of little

*Editor’s note: The author left this blank.

 Report of the Insane Asylums in Bengal, 1867 — 161

Interior view of a corridor in the asylum at Norristown, Pennsylvania, United

States (1896). Courtesy of the National Library of Medicine, Bethesda, MD.

worth, and I have not received from Sergeant Frawley, the Overseer, the
assistance I anticipated. He is greatly wanting in activity, and has not the
confidence or respect of his subordinates.

XII. I append a list of the visits paid to the Asylum during the year by
the Official Visitors:
Jan None
Feb Officiating Deputy Inspector General
Mar Deputy Inspector General; Judge; Joint Magistrate
Apr Deputy Inspector General
May Ditto Ditto
June Ditto Ditto
July Ditto Ditto
Aug Ditto Ditto
Sep Ditto Ditto
Oct Ditto Ditto Commissioner
Nov Ditto Ditto
Dec None
162 — The Asylum
I have the honor to be, Sir,
Your most obedient Servant,
R. F. Hutchinson, M.D.
Superintendent, Lunatic Asylum

From W. A. Green (Inspector General of Hospitals, Lower Provinces, Office of

Superintendent Government), Annual Report of the Insane Asylums in Bengal for the
Year 1867 (Calcutta: Office of Superintendent Government Printing, 1868), 71–75.

Elizabeth P. W. Packard
(1816–1897)

The Prisoners’ Hidden Life,

or Insane Asylums Unveiled
(1868)

Already in the eighteenth century, there were widely publicized

reports about sane individuals being committed against their will as
well as stories about the abuse of patients in asylums. By the second
half of the nineteenth century, novels and short stories, such as
Sheridan Le Fanu’s Uncle Silas (1864) and Charlotte Perkins
Gilman’s The Yellow Wallpaper (1899), were replete with tales of
madwomen kept in attics and of husbands or guardians attempting
to drive their wards mad. Such horror stories were reinforced
throughout the century by former patients who alleged they were
mistreated in asylums. Their memoirs often had sensational titles,
for example, Samuel Bruckshaw’s One More Proof of the Iniquitous
Abuse of Private Madhouses (1774) and Elizabeth Packard’s The Pris-
oners’ Hidden Life, or Insane Asylums Unveiled (1868). By the late
nineteenth century, these reports helped lend credence to calls for a
far-reaching reform of state hospitals.
The following is an excerpt from Elizabeth Packard’s The Prison-
ers’ Hidden Life. A champion for married women’s rights, Packard
 Packard, The Prisoners’ Hidden Life — 163
accused her husband of committing her to the Jacksonville Insane
Asylum in Illinois against her will. She claimed that her husband,
in collusion with the asylum’s director, kept her there for espousing
Calvinist religious beliefs. Eventually gaining her freedom, she pub-
lished a number of books in the years 1864–1868 about her expe-
riences, going on to form one of the first antipsychiatry associations
in the United States. Even in the absence of knowing the veracity of
her claims, her account below shows how conventional ideals of
femininity and family inflected early antipsychiatric sentiments.

Mrs. Cheneworth’s Suicide—Medical Abuse

Mrs. Cheneworth hung herself in her own room, after retiring from the
dancing party, last night. Her measure of grace was not sufficient to enable
her to bear the accumulated burdens of her hard fate any longer, without
driving her to desperation. I can not blame her for deliberately preferring
death, to such a life as she has been experiencing in this Asylum. She has
literally been driven to it by abuse.
She was entered in my ward, where she remained for several weeks,
when she was removed to the lowest ward, where she has been murdered
by slow tortures. If this Institution is not responsible for the life of Mrs.
Cheneworth, then I don’t know what murder is. She was evidently insane
when she entered; she was not responsible, although her reason was not
entirely dethroned. Her moral nature was keenly sensitive; her power of
self-control was crushed by disease and medical maltreatment. She resisted
until she evidently saw it was useless to expect justice, and was just crushed
beneath this powerful despotism.
She was a lovely woman, fitted by nature and education to be an orna-
ment to society and her family. Gentle and confiding, with a high sense
of honor and self-respect, she despised all degrading associations. . . . She
was a most accomplished dancer, having been trained in the school of the
best French dancers in the country. Her complexion white and clear, with
regular features, black, but mild and tender eyes, her hair was long, black,
and beautiful. In short, she was a little, beautiful, fawn-like creature,
when she came to this Institution. She had been here a short time once
before, after the birth of her first child; and from her account I inferred
164 — The Asylum
that her restoration to reason was not then attended with the grim spec-
tre of horrors which must have inevitably accompanied this.
She had left a young babe, this time, which her physician advised her
to wean, since she was now in a delicate condition. Thus her overtasked
physical nature, abused as it was by bad medical treatment, added to the
double burden she was called to endure, could not sustain the balance of
her mental faculties. Her nerves were unstrung, and lost their natural tone
by the influence of opium, that most deadly foe of nature, which evidently
caused her insanity. The opium was expected to operate as a quietus to her
then excited nervous system; but instead of this, it only increased her nerv-
ous irritability. The amount was then increased, and this course persisted,
until her system became drunk, as it were, by its influence. The effect pro-
duced was like that of excessive drinking, when it causes delirium tremens.
Thus she became a victim to that absurd practice of the medical profession,
which depends upon poisons instead of nature to cure disease.
What Mrs. Cheneworth wanted was, the nourishment of her
exhausted physical nature, by rest, food, air, and exercise. She did not need
to have the power of her system thrown into confusion by taxing them with
poisons, which nature must either counteract and resist, or be overcome by
them, and sink into death. Nature was importuning for help to bear her
burdens, being already overtasked. But instead of listening to these
demands, her blinded friends allowed her to be thus medically abused.
After having suffered her to receive this treatment, and thus brought into a
still worse condition—an insane state—when more than ever she needed
help and the most tender, watchful care; then to be cast off in her helpless-
ness upon strangers, who knew nothing of her character, her habits, her
propensities, her cravings, her disposition, or her constitution; how could
they reasonably expect her to thus receive the care necessary to her recov-
ery? They probably did expect it, and on this false expectation placed her
here for appropriate medical treatment.
What a delusion the world is laboring under, to expect such treatment
here! Did they but know the truth, they would find that all the “medical
treatment” they get here is to lock them up! and thus having hidden them
from observation, and cut them off from all communication with their
friends, they then inflict upon them what they consider condign punish-
ment for being insane! Why can not their friends bestow upon them this
“medical treatment” at home, without the expense of sending them to this
 Packard, The Prisoners’ Hidden Life — 165
Asylum to get it? This is the sum and substance of all the “treatment” they
get here, which they could not get at home—that is, they could not get this
treatment from reasonable friends, any where, outside of these inquisitorial
institutions. How doleful is this purgatory? thus legally upheld for the pun-
ishment of the innocent! Great God! Is this Institution located within the
province of thy just government? or is this Satan’s seat, that has not yet
been subjected to thy omnipotent power? . . .
Alas! for poor Mrs. Cheneworth! her days for reasonable treatment
expired when she was removed to the lowest ward, and consigned to the
care of Elizabeth Bonner. This attendant was a perfect contrast to her for-
mer attendants in character, disposition, and habits. She was a large, coarse,
stout, Irish woman, stronger than most men; of quick temper, very easily
thrown off its balance, when, for the time being, she would be a perfect
demon, lost to all traces of humanity. Her manners were very coarse and
masculine, a loud and boisterous talker, and a great liar, with no education,
and could neither read nor write.
To this vile ignorant woman was Mrs. Cheneworth entrusted, to treat
her just as her own feelings dictated. Miss Bonner’s first object was to
“subdue her,” that is, to break down her aspiring feelings, and bring her
into a state of cringing submission to her dictation. Here was a contest
between her naturally refined instincts, and Miss Bonner’s unrefined and
coarse nature. Any manifestation of the lady-like nature of Mrs. Che-
neworth, was met by its opposite in Miss Bonner’s servant-like nature
and position, and she must lord it over this gentle lady. The position of
the latter, as a boarder, must at her beck, be exchanged, by her being
made to feel that she was nothing but a slave and menial. If she ventured
to remonstrate against this wanton usurpation of authority over her, she
could only expect to receive physical abuse, such as she was poorly able
to bear. And O! the black tale of wrongs and cruel tortures this tender
woman experienced at the hand of this giant like tyrant no tongue or pen
can ever describe! She was choked, pounded, kicked, and plunged under
water, and well nigh strangled to death. Mrs. Coe assured me this was
only a specimen of the kind of treatment all were liable to receive at her
hands, since she claimed that this was the way to cure them! and this
insisted upon, was what she was put here to do. Being strong, she was
peculiarly adapted to her place, since no woman or man could grapple
with her successfully.
166 — The Asylum
The last time I saw Mrs. Cheneworth was at the dance, after which she
hung herself, being found suspended from the upper part of her window by
the facing of her dress. I never saw a person so changed. I did not know her
when Miss Bonner introduced me to her that evening. O, such a haggard
look! such despair and wretchedness as her countenance reflected, I have
never witnessed. My feelings were touched. I asked her to go with me, and
putting my arm around her waist, she walked with me across the ward to
the window looking South. Here we conversed confidentially, freely. She
said, “O, Mrs. Packard, I have suffered everything but death since we were
parted!”
“But how has your face become so disfigured by sores, and what causes
your eyes to be so inflamed?”
“I fainted, and fell down stairs, and they poured camphor so profusely
over my face, and into my eyes and ears, that I have, in consequence, been
blind and deaf for some time.”
I do not know whether her chin, which was red and raw, was thus
caused or not. She said the fall had caused her to miscarry, and thus,
thought I, you have had to bear this burden in addition to the load of sor-
rows already heaped upon your tender, weak person. Said I, “Have you any
hope of getting out of this place—of ever being taken to your friends?”
“No! none at all! Hopeless, endless torment is all that is before me!
O, if I could only get out of this place, I would walk to my father’s house.
It is only fourteen miles south here,” pointing out the window, “but O,
these iron bars! I can not escape through them.” . . .
Here we leave Mrs. Cheneworth, and turn with sorrowing hearts, to
the group of bereaved ones at home—those fondly loved ones, who have
thus been called to lay upon the altar of sacrifice, this precious victim.
O, could you have foreseen her sad fate, would you thus willingly have laid
her upon such an altar? No, you would not. You could not, and lay claim to
your humanity. You are not hard hearted and cruel towards this loved idol
of your fondest affections. No, you would have cherished her with the ten-
derest care at home, had you thought it would have promoted her best
good. Your hearts, I doubt not, wept the bitterest tears at the thought of
being compelled to place her in an Insane Asylum. But these tears could
not remove the necessity which you felt you had for so doing. Had you not
reason in your own mind for believing that Insane Asylums were estab-
lished for the benefit of the insane? Did you not suppose they had a com-
 Packard, The Prisoners’ Hidden Life — 167
petent medical faculty there, who knew better than yourselves how to treat
such cases? Yes, so you thought, as you ought to have had reason to think.
But alas! for a blinded public! Alas! for man who is placed under an irre-
sponsible human power. Such power, man is not fitted to be trusted with.
Despotism too soon usurps the rule of reason and kindness, and might
takes the place of right. Authority supplants kindness, truth, and honesty.
After this love of domineering has once taken possession of the human
soul, it can only be held by sinister, artful policy. Helplessness, weakness,
and dependence are the virgin soil where tyranny and despotism hold their
most resistless sway. But under the influence of our free government,
power would probably cope with it successfully; therefore its policy consists
in cutting off these victims from access to any power by which they would
be exposed and dethroned. Therefore, they not only prevent communica-
tions with their friends while there, but forestall their confidence in their
statements after they get out, assuring them they were so insane while
there that they can not report correctly, and therefore their representations
must be listened to as mere phantoms of a diseased imagination. Therefore,
their friends hear as though they heard not.
But the hitherto blinded public can no longer plead ignorance as an
excuse for not grappling successfully with this legalized despotism. No; the
Legislature of the State are already informed, through their own Commit-
tee, of the imperative need of such enactments, as shall hereafter forever
prevent such abuse of power, by any future Superintendent, as their present
incumbent is found to be notoriously guilty of.

From Mrs. E.P.W. Packard, The Prisoners’ Hidden Life; or, Insane Asylums Unveiled
(Chicago: E.P.W. Packard and A. B. Case, 1868), 202–211.
 Brain Science,
Nerves, and
Clinical Psychiatry

Nelson Sizer
(1812–1897)

Forty Years in Phrenology:

Embracing Recollections of History,
Anecdote, and Experience
(1891)

Although today it is often dismissed as little more than quackery,

phrenology—the study of the shape and size of crania and how
these relate to character attributes—was a serious discipline in the
nineteenth century and a precursor to the field of neurology. Its
founder, the Badenese anatomist and physician Franz Joseph Gall
(1758–1828), observed brain-damaged patients and came to the
conclusion that specific aptitudes, inclinations, and faculties were
associated with certain parts of the brain, which, in turn, left pecu-
liar traces on the skull.
Phrenologists, however, not only were involved in research.
They practiced as itinerant lecturers, psychological examiners, and
advisers. In the United States, one of the most successful group of
phrenologists were the siblings Orson, Charlotte, and Lorenzo
Fowler, who published a prominent journal on the subject and
founded consulting firms in major cities throughout the Northeast.
From 1838 until the turn of the century, they and their employees

168
 Sizer, Forty Years in Phrenology — 169

A model phrenological head. From Nelson Sizer and H. S. Drayton, Heads

and Faces, and How to Study Them: A Manual of Phrenology and Physiognomy for
the People (New York: Fowler & Wells, 1887), 195.

visited small towns, renting local churches or town halls and giving
lectures on phrenology. Along the way, they were often asked to
serve as counselors to parents, spouses, and business associates.
The following excerpt from the memoirs of the practitioner Nelson
Sizer, an employee of the Fowlers, gives us a sense of the ways in
which phrenologists served as incipient psychotherapists.
170 — Brain Science, Nerves, Clinical Psychiatry
Timid Child Managed—a Great Test

Another instance occurred in this town, the recital of which may serve to
aid some mother or teacher in the management of an unduly cautious child.
At the close of a lecture on the nature and training of the sentiments of
Approbativeness and Cautiousness, in which I had said that half the trouble
which people had with timid children was largely owing to their improper
management; adding that however much afraid of strangers any bright,
intelligent child, two or three years old, might be, I would undertake to get
it willingly into my lap in twenty minutes. A bright and genial lady came
up to the platform and said to me, “I have a boy two and a half years old,
that I think is bright, but he has never been in the lap of any person not
belonging to the family; even his grandpa, who has been in and out almost
daily for the last year, can make no headway in overcoming the child’s aver-
sion to strangers. Now, if you will come into my house and get that boy
into your lap, willingly, in twenty minutes or twenty hours, I will believe in
Phrenology.”
I found out where she lived and arranged to go there at one o’clock the
next day and to enter the dining room in the extension of the house, with-
out knocking and that neither she nor her husband should say any person
was coming, or look at or say a word to “Charlie” when I came, nor while
I stayed, and I was not to be treated as a stranger while there.
At the hour appointed I entered the house, the family was at the
table. Charlie slipped out of his chair and left for the kitchen as quick as
legs and “wings” could carry him. I instantly spoke in a tone of familiar-
ity to the parents: “What made you eat up all the dinner so that I can
have none? I will pick what I can get.” I took a seat at the table and began
to eat—and kept talking in a way that a child, which I felt certain was lis-
tening, would understand—then laying one hand on the father’s head
and the other on the mother’s, kept on telling them what they were fond
of and what they could do, and stealthily turning toward the open door
into the kitchen, saw about half of the little head and one bright eye peep-
ing around the door jamb, of course wondering who and what that
stranger could be who seemed so much at home with the house, the din-
ner, and the parents. I went on examining the heads and talking, keeping
my back toward the little spectator, who forgot that I saw him leave the
room, and, perhaps supposed I did not know he had existence. He edged
 Sizer, Forty Years in Phrenology — 171
his way into the room, and as he was against the wall quite a distance
from the door, I kept turning my back toward and my face directly from
him so as to compel him to get very near me before he could see the face
of the drollest man that ever he saw in his home. Of course the plan was
to ignore the boy, yet to talk so that he could comprehend it. All at once
I walked away from the boy to the opposite side of the room and looking
up to a gaudy picture, representing Solomon’s temple, with the Sanhedrin
in session wearing their red robes, I said, “What a splendid picture Char-
lie has here!” and then I kept on describing the figures of the council and
calling them men and ladies and boys, and I dropped my eye and he stood
by my side eagerly looking to learn, for the first time, the mysteries of the
great picture which, the stranger had said, was Charlie’s. He had forgot-
ten that I was a stranger in the sense of being dangerous. I had said noth-
ing to him, had not looked at him, had not tried to have him come to me,
but had let him alone, and talked steadily about what he could not under-
stand, and he had got all the faculties of curiosity aroused, and his Cau-
tiousness had gone to sleep.
I stooped and picked him up saying, “You can’t half see it down there,
I will show you all about it.” And his finger on the picture with mine try-
ing to tell me what he could of its new-found beauties. The fact that it was
his, was a new thing to him, and I seemed to him to know more about his
interests and possessions than his mother did.
I then set him down, for fear it would occur to him that I was a
stranger, and walked right away from him and went where his father and
mother sat, marked off a chart for the mother, and the boy was leaning
against me, apparently very much at home, and trying to be interested in
what I was doing. I opened my chart, which contained pictures, and told
Charlie if he wanted to see the picture he might come now, and he climbed
into my lap without assistance, while I kept the pictures of the book out of
the reach of his eyes until he had got fairly into my lap. It was a struggle,
and when he got fixed and gave a sigh of contentment, I turned toward the
blazing and half tearful eyes of the mother interrogatively, and she burst
out, “I give it up. Oh, how did you do it?”
I quietly replied, “I made no appeal to his Cautiousness, but did every-
thing to allay that feeling, and to awaken curiosity and excite his judgment,
imagination, and affection. Ignoring him was just what he needed, yet it was
what others did not do, and you always tried to urge him to pay attention
172 — Brain Science, Nerves, Clinical Psychiatry
to the stranger, and make friends with him. That defeated its own purpose.
I took a different course, and you see the result.”
The boy talked of me for months afterward, and wanted me to “come
some more.” This method of curing timidity I always use when necessary,
and it is wonderful how quickly other faculties can be awakened, and Cau-
tiousness be allayed. A timid child is talked to and coaxed by every one that
calls, and so grows worse. If left alone and unnoticed, it would soon get over
its bashfulness.

“A Spoiled Child, and How It Was Done.”

“Mistaken severity as well as mistaken kindness will equally, but very dif-
ferently, spoil a child. As over-indulgence in every whim or imaginary want
of a child leads to effeminacy, amiable selfishness, capricious exactions from
friends and servants, and a general helplessness; so, on the other hand, too
much strictness and severity in the training ruins the temper and makes a
vixen to torture the next generation, or utterly crushes the spirit and makes
life to the child a ‘vale of tears.’ We give a case in point:
“I examined in this place the head of a little girl four years old, and
found Destructiveness and Combativeness very largely developed. Won-
dering why these organs should be so large, I referred to the heads of the
father and mother and a younger child, and found that none of them had
those organs in more than a medium degree. This, of course, excited my
surprise, and I felt it necessary to account for the discrepancy, or ascertain
the history of the case. Accordingly, I suggested to the parent that the child
must have been very much annoyed and irritated by surrounding influences
to induce at so early an age such extraordinary developments.
“The mother, with regretful earnestness, replied: ‘That is true, and I
will explain the reason. I have been a teacher and “boarded around,” and
seeing much slackness and imbecility in parental government, I firmly
resolved if I ever had children, I would begin with them in season and make
them go straight. Accordingly, this girl being my first child, I began early to
make her toe the mark, and I used to train and whip her for every little
offense or neglect. She has become fretful, peevish, and violent in temper,
so that now, whipping only makes her worse. A few days ago I lost my tem-
per and gave her a severe whipping, and the moment I got through with her
she seized the fire-tongs, and with a severe blow she broke the back of her
 Sizer, Forty Years in Phrenology — 173
pet kitten that was sitting by the fire. When her anger had subsided she
mourned piteously for the death of her pet, and she can not get over her
loss. She is a very bad child when angry, and I do not know what I can do
with her. I have, however, taken a very different course with my other one,
and she is easily managed, though her natural disposition is no more ami-
able than that of the older one was at first. I fear I have spoiled my little girl
by unnecessary strictness and severity.’”
This painful fact has doubtless since then helped me in hundreds of
instances, to guide and aid other mothers in the adoption of better meth-
ods in the training of their precious pets, whose upgrowth to goodness and
to God was the hope and the burden of their life. . . .

Insanity Cured by Phrenology

While here, I received a call from a friend residing twelve miles distant, at
Suffield, Conn., where I married my wife and resided during 1843. He
informed me that Henry Bissell, of Suffield, had recently received a blow
upon the head in the region of the temple, and had become insane in con-
sequence. He appeared somewhat strangely for a day or two, and then took
the train for New York, and before arriving there, attracted attention by
immoderate laughter at everybody and everything in the car. A gentleman
who knew him happened to be on the train, and took him back to Hartford,
left him in the asylum, and sent for his father. Here he had been for several
weeks under treatment without any apparent benefit. On hearing these
facts I wrote at once to the father, and sent it by my informant, stating the
impression that the injury was upon the seat of Mirthfulness, hence his
tendency to laugh and see absurdity in everything, and suggested that if the
physician would apply leeches and ice to that part of the head which was
injured, the symptoms of insanity would cease. The aged father, who was
interested in our lectures on Phrenology at Suffield in 1841, recognizing
the reasonableness of the views that I had taken of the cause and proper
treatment of the case, on receiving my letter at eight o’clock that night he
instantly harnessed his team for a dreary drive of seventeen miles to Hart-
ford, and, reaching the asylum at eleven o’clock, after Dr. Butler had retired,
he insisted upon seeing him at once. With my letter open in his hand, the
anxious father met the doctor, who read it deliberately and said: “It looks
reasonable, and we will try the treatment in the morning.”
174 — Brain Science, Nerves, Clinical Psychiatry
“No, doctor; we will try it to-night, if you please. I can not wait till
morning.”
“All right,” said the doctor, “to-night, if you say so.”
In half an hour the patient was under the treatment of leeches, in
another half hour the injured part was under the influence of pounded ice,
and he was fast asleep. The next morning he and his father took breakfast
with the doctor; “he was clothed and in his right mind,” and in a short time
went home with his father, apparently cured.
The injury was directly over the organ of Mirthfulness, and the inflam-
mation caused by the blow, produced the deranged action of that faculty.
Thirty-seven years have now elapsed, since this injury was received and
cured, and there has been no return of the symptoms of insanity. Had the
inflammation been allowed to proceed, death, or mental derangement for
life, might have been the consequence. The young man being my friend, I
felt peculiar interest in the case.
Thus Phrenology throws a flood of light on the subject of insanity for
those who wish to learn.

Trades Selected for Boys

“I am from Patterson, sir; you will remember I brought to you my three

elder boys, and you selected for each of them the trade he was best fitted
for, and they are thriving at them nicely, and say they could not and would
not change trades on any account. They often talk about it, and each boasts
over the other that he has the best trade of the lot. Now I have brought this
one, and I shall put him to the trade you say he is best adapted to. I believe
you know about it, for you have placed the other three so well, and the
trades are so different; only think one is a jeweler, one is a butcher, and the
other is a carpenter. I have one more besides this, and I shall bring him
when he is old enough to put to business.”
And this is not the only family who is doing a similar thing, and such
work serves to keep us up to a sense of our responsibility.

From Nelson Sizer, Forty Years in Phrenology: Embracing Recollections of History, Anec-
dote, and Experience (New York: Fowler and Wells, 1891), 63–67, 73–74, 188–189,
295–296.
 Beard, Cases of Hysteria — 175

George Miller Beard

(1839–1883)

Cases of Hysteria, Neurasthenia,

Spinal Irritation, or Allied Affections
(1874)

Similar to scholars in the eighteenth century, observers on both

sides of the Atlantic during the last third of the nineteenth century
came to believe that nerves played a pivotal role in human health.
The brain was often compared to a battery producing electricity that
passed its energy through nerve fibres in a manner akin to the way
in which electrical wires function. Too much or too little nervous
energy, it was believed, could lead to a disequilibrium that came to
be known as a “nervous breakdown.”
George Miller Beard became one of the most famous proponents
of this view. Beard began his career as an electrotherapist, following
a tradition, which went back to the eighteenth century, of adminis-
tering electrical current to individuals suffering from any number of
different ailments, including paralysis, rheumatism, indigestion,
headaches, and impotence. In 1869, he published an article
announcing a new diagnosis, neurasthenia, a disease he believed was
caused by the hectic pace and demands of modern life.

Under this head I propose to detail a few cases of nervous disease—com-

monly called functional—that are at once exceedingly frequent and exceed-
ingly annoying both to patients and physicians. I shall treat the subject
mainly from the clinical and practical stand-point, reserving the discussion
of its scientific and philosophic relations for another occasion.
By hysteria and allied affections I mean that large and increasingly
numerous class of affections that pass among the people and among the
profession by the vague and half-erroneous terms, spinal irritation, nervous
exhaustion, general debility, general neuralgia, etc.
176 — Brain Science, Nerves, Clinical Psychiatry
In a work in which I have long engaged, and which is now slowly pro-
gressing, I hope to be able to unify these diseases—to show that they have
in general a common pathology, a common history, a common group of
symptoms, and a common therapeutics. I shall seek to show that these dis-
eases, or symptoms of diseases—or, as they might, perhaps, with better
justice be called, results of disease—are expressions of a common nervous
diathesis; that they are all liable to run into each other, and to act vicari-
ously to each other; that they are part of the price we pay for civilization,
being confined mostly to the enlightened peoples of modern times; and that
they are, in all their dreary shapes, most abundant in the northern portions
of the United States of America. . . .

General Principles of Treatment

I treat all these affections, by whatever name known, on the same general
principles, varying and adapting the method according to individual need.
Of the various methods of using electricity, I depend mainly on general
faradization and central galvanization, using sometimes in alternation—in
some cases finding the former, in others the latter, more beneficial.*
Internally, I use preparations of phosphorous and cod-liver oil, and
sometimes arsenic. I make large use of the cod-liver oil emulsion. I have
seen good results from the oxide and phosphide of zinc and chemical food.
Externally, I use ice and hot-water bags to the spine with studious cau-
tion, and mild and cautious counter-irritation to tenders points on the
spine. My method of counter-irritating nervous patients is, to take one of
Alcock’s porous plasters and cut off a piece of about the size and shape of
my little finger;† along the centre of this I place a little Spanish-fly ointment,
and then apply over the tender spot, and let it stay there until it falls off.
Counter-irritation thus used is not very annoying, and is quite effective. I
use Alcock’s porous plaster because it sticks better than anything I can find.
Except when I am experimenting, I use all these remedies, or several of
them, simultaneously.

*Editor’s note: Faradization involved applying alternating current, while galvaniza-

tion referred to the application of continuous, direct current.
†
Editor’s note: Alcock’s Porous Plasters were adhesives purported to have electrify-
ing properties that could alter blood circulation.
 Beard, Cases of Hysteria — 177
Neurasthenia, Cerebrasthenia, Myelasthenia

The old and forgotten term, neurasthenia, I have for several years applied to
the condition known in common language as nervous exhaustion; and I have
recently subdivided this condition into cerebrasthenia and myelasthenia,
according as the exhaustion is chiefly manifested in the brain or in the
spinal cord. When the exhaustion shows itself chiefly in the brain, there
are the symptoms of insomnia, headache, vertigo, flashes before the eyes,
muscae volitantes, tinnitus, etc. When the exhaustion shows itself chiefly
in the spinal cords, there are the symptoms of pain in the back, at any point
below the first cervical and last dorsal vertebrae, and mostly between the
shoulder and in the lumbar region; spinal tenderness (though not always);
weakness of the lower limbs, and sometimes of the arms; flatulence; feeling
of oppression on the chest; gastralgia, intercostal and abdominal; neuralgia
of the bladder and sexual disturbance; numbness of the extremities, etc.
While the term neurasthenia implies both cerebrasthenia and myelasthe-
nia, yet in some cases the exhaustion seems to be almost exclusively con-
fined to the brain alone, or to the spinal cord alone. . . . The meaning of
these terms will be made more clear by the following cases:
Case I. Mr. L———,aged 86, was referred to me, June 25, 1873, by
Dr. Geo. Baker. For several months, since January 1873, the patient had
suffered from vertigo, feeling of tingling, pricking, and stinging over the sur-
face of the body; pain in the back; dyspepsia; constipation, insomnia, and
mental depression. The spinal irritation was quite variable in its seat, being
sometimes in the lower, sometimes in the upper vertebrae. Sometimes
there was tenderness of the cervical vertebrae, with stiffness of the neck.
The diagnosis was neurasthenia, including cerebrasthenia and myelas-
thenia; and the pretty evident cause was excess in sexual indulgence com-
bined with over work in business.
I gave general faradization alternately with central galvanization, for
one month; and, at the same time, used phosphide of zinc pills in doses of
1–10 of a grain, and chemical food. Counter-irritation was also employed
over the tender vertebrae. July 5, he was much better. August 1, still bet-
ter; and September 1 he resumed active business.
Case IV. Miss G———, a young lady of about 24 years of age, was
first seen, with D.O.L. Mitchell, Nov. 23, 1871. The patient was of a very
fine organization, and of slight, fragile build. Left an orphan at an early age,
178 — Brain Science, Nerves, Clinical Psychiatry
she had worked hard as a copyist in a telegraph office, where she toiled
many hours a day to support herself and her younger brothers and sisters.
For two years or more she had been in a condition of excessive debility,
which her physician could control only imperfectly by medication.
She could not walk a single block, or even part of a block, and so
remained constantly indoors. Her appetite was feeble and fickle; sleep was
uncertain and disturbed; the circulation unequal. The pulse, though weak
and nervous, was yet tolerably strong for a delicate lady, but was very sus-
ceptible to mental influence. Careful examinations had been able to detect
no disease of the lungs or heart or of any organ; the uterus had not been
examined.
Fainting spells, or spells resembling fainting, came over her after severe
exertion; even the shock of hearing the door open fearfully agitated her, so
that she suffered for a number of minutes. She dreaded the coming of a new
doctor, and lived in a condition of painful apprehension when she learned
that I was to be called in to see her.
To all medication she was extremely susceptible; even a few drops of dilute
phosphoric acid seemed to do injury. Similarly tonics and stimulants were
badly borne. Some mental depression accompanied all these symptoms; but
the patient had considerable force of will, and when in good health was very
energetic. There were no fits of laughing or crying.
After a careful and thorough trial of general faradization, central galva-
nization, and galvanization of the cervical sympathetic, I gave up the case.
She bore electricity as she bore everything else—badly, and no amount of
treatment succeeded in bringing her to that condition where she could tol-
erate an average dose of either treatment.
During the latter part of the treatment the uterus was carefully exam-
ined by Dr. Skene, who found a tendency to vaginismus and anteflexion;
but these symptoms were regarded merely as accompanying or incidental
phenomena, and were not treated.
After electrical treatment was abandoned time came slowly to the res-
cue, and, under the care of her physician, she so far improved as to be able
to walk out, but she subsequently relapsed.
This case illustrates: First, that there are certain temperaments that will
not bear electricity; secondly, that in nerve functional disturbances time,
rest, and hygiene may cure or greatly relieve, after medication has failed. In
all these cases special pains must be taken to avoid exertion, mental or mus-
 Tamburini, “A Theory of Hallucinations” — 179
cular. A slight indiscretion may put back the patient for weeks or months.
For the nervously exhausted to overdo, even for an hour, is a blunder that
is almost a crime.

From George Miller Beard, Cases of Hysteria, Neurasthenia, Spinal Irritation, or Allied
Affections (Chicago: Spalding, 1874), 1–4, 6-7.

Auguste Tamburini
(1848–1919)

“A Theory of Hallucinations”
(1881)

The Italian Auguste Tamburini was an academic psychiatrist who

served as both director of one of Europe’s oldest asylums (San Laz-
zaro) and as a professor of psychiatry and neurology. He eventually
became director of the psychiatric institute in Rome in 1907. Tam-
burini’s article on the theory of hallucinations, published in French
in 1881, was among the most cited in late nineteenth-century neuro-
psychiatry. It quickly inspired countless researchers and clinicians
to see hallucinations no longer as possessing some kind of semantic
meaning, but instead as products of mechanical processes involving
the brain and nervous system.

There has been much debate on the nature and brain localization of hallu-
cinations. This is to be expected as these phenomena are not only impor-
tant symptoms of insanity and a cause of delusions, but have also played a
role in history. Four types of explanation are available for their origin: (1)
peripheral; (2) intellectual; (3) psycho-sensorial; and (4) sensorial.
According to the peripheral view, as stated in the writings of Erasmus
Darwin, Foville and Michéa, hallucinations are subjective sensations caused
by the peripheral irritation of sensory organs. As evidence, the authors
quote the development of unilateral hallucinations in association with
180 — Brain Science, Nerves, Clinical Psychiatry
morbid changes in peripheral sense organs or the distortion of image
caused by manual pressure on the eye. This view fails to explain the pres-
ence of hallucination in cases when the peripheral sense organ has been
completely destroyed.
The “intellectualistic” view of hallucinations attributes the origin to
disturbances of imagination and memory and has been supported by
Esquirol, Lauret, Lélut, Falret, Reil, Neumann, Parchappe, Brierre de Bries-
mont, Delasiauve, Maudsley, etc. According to these authors hallucinations
are thoughts changed into sensations; they are projections, so to speak, of
the sensorial aspects of ideas on to the external world. Hallucinations are
sensory delusions. Against this view is the fact that hallucinations are often
thematically unrelated to normal or pathological ideas. Likewise this
hypothesis is unable to explain the clinical facts listed by those supporting
the peripheral view.
The psycho-sensorial theory is a combination of the two views above,
and explains more clinical observations than either of them alone. Both
intellectual and peripheral centres would participate in the constitution of
the hallucinatory phenomenon. The theory has been supported by Müller,
Griesinger, Baillarger, Moreau de Tours, Marcé, Motet, and more recently
by Ball. The problem with this view is that, because it describes hallucina-
tions in a general way, it explains everything; even worse, it does not take
into consideration recent advances in neurophysiology.
According to the fourth view, the one more in keeping with modern
brain anatomy and physiology, hallucinations are the result of activity in
the sensory centres of the brain. This view, therefore, postulates the exis-
tence of sensory centres in the central nervous system to which sensory
information is conveyed by sensory nerves. Morbid changes in these brain
sites would give rise to hallucinatory experiences. Already hinted at in the
work of Baillarger and Schröder Van der Kolk, this view has recently been
expressed with great clarity by Kahlbaum and Hagen, and adopted by
Koppe, Jolly, Hoffmann, Luys and Ritti.
How is that sensations generated in these brain centres can give rise to
images endowed with all features of reality? According to Hagen all periph-
eral stimuli arriving at the sensory centres are immediately diverted to two
destinations: the ideational centres (where they will generate images in
consciousness) and back to the periphery (by the principle of external pro-
jection). Stimuli generated in the brain sites themselves would suffer the
 Tamburini, “A Theory of Hallucinations” — 181
same fate, thereby giving rise to apparent perceptions. This view explains
all clinical facts but requires periodical updating according to the progress
of brain anatomy and physiology.
The next question is, where are the brain centres for hallucinations?
Krafft-Ebing, Hoffmann, Leidersdorf and others have not provided an
answer and simply refer to them as the sites where sensory nerves termi-
nate. Hagen and Kahlbaum, on the other hand, have suggested that these
centres are, in fact, the basal ganglia or sensory brain (Sinnhirn). Bergmann,
in turn, has claimed that the sensory nerves terminate in the walls of the
cerebral ventricles where, by means of a resonance mechanism, perceptions
are constituted. Hallucinations would result from an irritation in these
areas: the third ventricle would be associated with visual hallucinations, the
fourth ventricle with auditory ones. . . .
Recent work, however, seems to suggest that sensory fibres do termi-
nate in the cortex itself. . . . Panizza’s “Observations on the optic nerve” was
originally published in the Journal of the Lombard Institute for August
1855 and reprinted a year later. It reports experiments carried out on mam-
mals, birds and fish by two methods: (1) selective lesioning of cortical sites
followed by evaluation of visual function, and (2) eyeball enuncleation fol-
lowed by analysis of retrograde nerve atrophy. Panizza wrote that in the dog
“removal of cortical substance under the parietal areas causes contralateral
blindness.” He also showed retrograde atrophy of the optic nerve in the rab-
bit, horse, dog, ox, and sheep. He mapped the atrophic changes in the genic-
ulate bodies, thalamus and even in the fibres arriving in the striatal area.
Clinical data suggest that this also applies to the human. For example,
a traumatic lesion of the left eye caused atrophy in a three-year-old; a post
mortem after his early death at age 16 showed parietal-occipital atrophy
involving the right thalamus and hemisphere. After a right stroke a second
patient developed amaurosis of the right eye and post-mortem showed soft-
ening of the posterior hemisphere. Panizza concluded that in the mammal
the optic nerve receives contributions from the geniculate bodies, thalamus,
and occipital lobe. His work has been replicated by Hitzig and Ferrier. . . .
These findings may help to explain the genesis of hallucinations. If
there are cortical centres where sensory impressions become perceptions
(and where they are also stored as mnemonic images), then it would be
surprising that they did not play a role in the production of hallucinations.
In the same way that irritation of motor centres may cause disorganized
182 — Brain Science, Nerves, Clinical Psychiatry
(epileptic) movements, morbid changes in sensory ones would cause patho-
logical sensations.
What, however, would the origin of the sensations be? They are likely
to be mnemonic images, stored impressions, which after being revived by
the morbid process would with varying vividness (according to the strength
of the irritation) present themselves to consciousness. When accompanied
by all sensory features they would be perceived as real and hence constitute
hallucinations proper. When the irritation is unilateral or limited to a dis-
crete cortical area, the hallucination will occur in one specific sense modal-
ity (e.g. visual or auditory) and be unilateral; if the morbid process is
bilateral, diffuse and involving more than one sensory centre, a composite
hallucination involving all sense modalities might be experienced.
Acceptance of this hypothesis should depend on its being (a) in keep-
ing with what is known in brain physiology, (b) in agreement with the facts
of clinical observation, and (c) able to explain the diverse clinical presenta-
tions of hallucinations as reported by those who postulate rival theories
(peripheral, psychical or mixed).
With regards to (a) above it has already been stated that the sensory
centre hypothesis is in keeping with current knowledge of cortical physiol-
ogy. An inkling of this view, which would make sense even if no facts on
cortical physiology were yet known (as it is presented in the work of Meyn-
ert, Wundt and Hughlings-Jackson), can be found in the work of Ferrier
when he reported that eyeball and ear movements followed electrical stim-
ulation of the sensory centres, and that these were likely to be related to the
projection of experienced images on to the external world (which the exper-
imental animal would perceive as real objects). Thus, whilst stimuli applied
to the motor centres cause epileptic movements, stimuli applied to the sen-
sory centres generate hallucinations.
But the hypothesis must also be in accord with clinico-pathological
observations. The point here is to determine whether subjects presenting
with clear cut hallucinations will also exhibit relevant cortical lesions on
post-mortem. It must be remembered that hallucinations are a transient
phenomenon which tends to occur during the early stages of psychoses and
that the irritation that causes them in the first place is unlikely to persist
until the patient comes to post-mortem. Hallucinations may also be
replaced by the symptoms of mental degeneration. Furthermore, even if the
subject died whilst experiencing hallucinations, lesions may not be visible
 Tamburini, “A Theory of Hallucinations” — 183
because of their irritative nature, as it is indeed the case with regards to irri-
tative lesions in motor areas. Therefore, it is easy to imagine how difficult it
is to accumulate evidence to confirm the hypothesis. Very few cases meet-
ing these requirements have been reported in the literature (such as those
by Ferrier, Pooley, Atkins and Gowers). Their common feature is that visual
hallucinations were experienced only during the early irritative stage, and
that the destructive stage of the lesion was followed by loss of vision. . . .
The third condition dictates that the hypothesis provide adequate
explanation for all clinical presentations of hallucinations. For example,
how to explain the fact that hallucinations precede or follow delusions.
Both situations can be accommodated by this theory on the basis that it is
unlikely that lesions causing hallucinations always occur on their own.
Often, in fact, they are accompanied by other brain lesions. So, if the first
lesion is on a sensory centre, hallucinations will precede delusions; if it is
on the ideational centre it will be the other way around. This explanation
is valid provided that it is not assumed that ideation is but a complex form
of activity taking place in the sensory centres themselves.
In favor of a separation between ideational and sensory centres is the
fact that psychologically healthy subjects have no difficulty in recognizing
interloping sensations as hallucinations. This capacity for insight, however,
cannot be explained either by the peripheral or psychical theory of halluci-
nations. The peripheral theory is also rendered implausible by the fact that
hallucinations tend to be cognitively complex; and the psychical theory by
the fact that they are often sensorially vivid. Both objections are easily dealt
with by the theory that hallucinations result from irritation of the cortical
sensory centres. . . .
It can be concluded that many aspects of hallucinations not explained
by other theories are accounted for by the view proposed in this paper. This
is based on the most recent anatomical, physiological and clinical findings,
and postulates that the fundamental mechanism for hallucinations is a state
of morbid excitation of cortical sensory centres, of sites where sensory
impression from the peripheral organs are collected and transformed into
perceptions, and where their mnemonic images are stored.

From Auguste Tamburini, “A Theory of Hallucinations,” History of Psychiatry 1

(1990): 151–156 (© History of Psychiatry, 1990), by permission of Sage Publica-
tions Ltd.
184 — Brain Science, Nerves, Clinical Psychiatry

Richard von Krafft-Ebing

(1840–1902)

Psychopathia Sexualis
(1892)

Since ancient times, Western religions have inveighed against vari-

ous forms of deviant sexual behavior. And while medicine often
appeared to be less prudish about commending the benefits of an
active sex life, physicians nonetheless often warned of the health
dangers posed by venereal diseases and masturbation. Over the
course of the nineteenth century, however, a new trend emerged, as
researchers and practitioners began applying clinical notions of nor-
mality and abnormality to classify, diagnose, and treat sexual
deviants.
Richard von Krafft-Ebing’s Psychopathia Sexualis was the culmi-
nation of this trend. An older contemporary of Emil Kraepelin and
Sigmund Freud, Krafft-Ebing practiced psychiatry in various Ger-
man asylums and clinics, until eventually settling in Vienna. Psycho-
pathia Sexualis detailed his work with patients complaining of
“perversions,” which at that time included homosexuality, sadism,
masochism, and exhibitionism. First published in German in 1886,
the book was a scholarly best seller, going through numerous
reprints and new editions during Krafft-Ebing’s lifetime. As these
excerpts show, the book was readily available to the general public,
leading many readers to see their sexual proclivities in a new light.
In fact, many readers were so moved that they contacted Krafft-
Ebing and shared their own stories with him. He, in turn, incor-
porated many of their tales into subsequent editions of his book
(see cases 136 and 137, below). As a result, Psychopathia Sexualis
gives us both a sense of how Krafft-Ebing operated — note his
reliance on hypnosis, a very common form of treatment at this
time—as well as insight into how self-identified “perverts” lived
with their desires.
 Krafft-Ebing, Psychopathia Sexualis — 185
While up to this time contrary sexual instinct has had but an anthropo-
logical, clinical, and forensic interest for science, now, as a result of the lat-
est investigations, there is some thought of therapy in this incurable
condition, which so heavily burdens its victims, socially, morally, and
mentally.
A preparatory step for the application of therapeutic measures is the
exact differentiation of the acquired from the congenital cases; and among
the latter, again, the assignment of the concrete case to its proper position
in the categories that have been established empirically.
The diagnostic differentiation of the acquired from the congenital con-
dition is made without difficulty in the early stages of the anomaly.
If sexual inversion has already taken place, then the history of the devel-
opment of the case will throw light upon it.
The important decision, prognostically, as to whether the contrary sex-
ual instinct is congenital or acquired, can only be made in such cases by
means of the most minute details of the history.
The establishment of the fact that contrary sexual instinct existed
before indulgence in masturbation is of great importance with reference to
deciding whether the anomaly is congenital or not. In this, however, a dif-
ficulty arises, owing to the possibility of imperfect localization of past
events (illusions of memory).
For the presumption of acquired contrary sexual instinct, it is impor-
tant to prove the existence of hetero-sexual instinct before the beginning of
solitary or mutual onanism.
In general, the acquired cases are characterized in that:—
1. The homo-sexual instinct appears secondarily, and always may be
referred to influences (masturbatic neurasthenia, mental) which
disturbed normal sexual satisfaction. It is, however, probable that
here, in spite of the powerful sensual libido, the feeling and inclina-
tion for the opposite sex are weak ab origine, especially in a spiritual
and aesthetic sense.
2. The homo-sexual instinct, as long as inversio sexualis has not taken
place, is looked upon, by the individual affected, as vicious and
abnormal, and yielded to only faute de mieux.
3. The hetero-sexual instinct long remains predominant, and the
impossibility of its satisfaction gives pain. It weakens in proportion
as the homo-sexual feeling gains in strength.
186 — Brain Science, Nerves, Clinical Psychiatry
On the other hand, in congenital cases (a) the homo-sexual instinct
is the one that occurs primarily, and becomes dominant in the vita sex-
ualis. It appears as the natural manner of satisfaction, and also domi-
nates the dream-life of the individual. (b) The hetero-sexual instinct
fails completely, or, if it should make its appearance during the life of
the individual (psycho-sexual hermaphroditism), it is still but an
episodical phenomenon which has no root in the mental constitution
of the individual and is essentially but a means of satisfaction of sexual
desire. . . .
The prognosis of the cases of acquired contrary sexual instinct is, at all
events, much more favorable than that of the congenital cases. In the for-
mer, the occurrence of effemination—the mental inversion of the individ-
ual, in the sense of perverse sexual feeling—is the limit beyond which there
is no longer hope of benefit from therapy. In the congenital cases, the vari-
ous categories established in this book form as many stages of psycho-sex-
ual taint, and benefit is probable only within the category of the psychical
hermaphrodites, though possible (vide the case of Schrenk-Notzing) in that
of the urnings.*
The prophylaxis of these conditions becomes thus the more impor-
tant,—for the congenital cases, prohibition of the reproduction of such
unfortunates; for the acquired cases, protection from the injurious influ-
ences which experience teaches may lead to the fatal inversion of the sexual
instinct.
Numerous predisposed individuals meet this sad fate, because parents
and teachers have no suspicion of the danger which masturbation brings in
its train to such children.
In many schools and academies masturbation and vice are actually cul-
tivated. At present much too little attention is given to the mental and
moral peculiarities of the pupils. If only the tasks are done, nothing more is
asked. That many pupils are thus ruined in body and soul is never consid-
ered. In obedience to affected prudery, the vita sexualis is veiled from the
developing youth, and the slightest attention given to the excitations of his
sexual instinct. How few family physicians are ever called in, during the
years of development of children, to give advice to their patients that are
often so greatly predisposed!

*Editor’s note: Urning was a nineteenth-century term for “homosexual.”

 Krafft-Ebing, Psychopathia Sexualis — 187
It is thought that all must be left to Nature; in the meantime, Nature
rises in her power, and leads the helpless, unprotected innocent into dan-
gerous by-paths.
A more detailed treatment of this prophylactic side of the subject is
impossible here.
To parents and teachers, the experiences detailed in this work, and
numerous scientific works on masturbation, give suggestions.
The lines of treatment, when contrary sexual instinct exists, are the
following:—
1. Prevention of onanism, and removal of other influences injurious to
the vita sexualis.
2. Cure of the neurosis (neurasthenia sexualis and universalis) arising
out of the unhygienic conditions of the vita sexualis.
3. Mental treatment, in the sense of combating homosexual, and
encouraging hetero-sexual, feelings and impulses. . . .

Case 136. Acquired Contrary Sexual Instinct.— Mr. Z., aged 32, divorced.
He comes of a hysteropathic mother. Maternal grandmother suffered with
hysteria, and her brothers and sisters were neurotic. One brother is an urn-
ing. Z. was but poorly endowed mentally, and did not learn easily. No sick-
ness besides scarlatina. When thirteen, he was taught to masturbate by
companions in a school. Sexually, he was hyperaesthetic, and, at seventeen,
began to indulge in coitus, with full pleasure and power. For reasons of
position and money, he married at twenty-six. The marriage was very
unhappy. After a year Mrs. Z. became incapable of coitus, by reason of uter-
ine disease. Z. satisfied his inordinate desires with other women, faute de
mieux, by masturbation. Besides, he gave himself up to play, led an
absolutely dissolute life, became exceedingly neurasthenic, and sought to
strengthen his weakened nerves by drinking great quantities of wine and
brandy. To his essential cerebral asthenia were added peripheral alcoholic
cramps and globus, and he became very emotional. His libido nimia con-
tinued unabated. On account of his disgust of prostitutes and fear of infec-
tion, satisfaction by coitus was exceptional. For the most part, the patient
helped himself with onanism.
Four years ago he noticed weakening of erection and decrease of libido
for women. He began to feel himself drawn toward men, and his lascivious
dreams were no longer concerned with women, but with men.
188 — Brain Science, Nerves, Clinical Psychiatry
Three years ago, while being rubbed by a bath-attendant, he became
powerfully excited sexually (the attendant also had an erection, to patient’s
surprise). He could not keep from embracing and kissing the attendant,
and allowing him to perform masturbation on him, the attendant doing it
most willingly. From this time this mode of indulgence was all that he
cared for. Women became a matter of entire indifference to him; he
devoted himself exclusively to men. With them he practiced mutual mas-
turbation, and had a longing to sleep with them. He abhorred pederasty.
He was entirely satisfied until (August, 1890) an anonymous letter, warn-
ing him to be careful, brought him to his senses. He was much frightened,
had hysterical attacks, and became much depressed. He was embarrassed
before men, seemed like a pariah in society, contemplated suicide, and
finally confessed to a priest, who comforted him. He now fell into a reli-
gious state (equivalent), and, out of remorse and to cure himself of his
abnormal sexual inclinations, wished to go into a cloister. While in this
state, my “Psychopathia Sexualis” fell into his hands. He was frightened
and filled with shame, but found comfort in it, inasmuch as he concluded
that he must have some malady. His first thought was to rehabilitate him-
self sexually in his own eyes. He overcame all disinclinations, and visited a
brothel. At first he was not successful, on account of great excitement, but
he finally succeeded.
Since, however, his contrary sexual inclinations were not overcome, in
spite of all his efforts to put them down, he finally came to me, asking for
assistance. He felt himself to be terribly unfortunate, and very near to
despair and suicide. He saw destruction before him, and would be saved at
any price.
His confession was interrupted by numerous hysterical attacks.
Comforting and encouraging words about his future had a calming
influence. . . .
Hip-baths, massage, ergot with antipyrin and pot. brom., ordered, with
interdiction of onanism, intercourse with men, and lascivious thoughts of
them.
After a few days the patient came complaining that he was not equal to
the task. He said his will was too weak. In this precarious situation, it
seemed that nothing but hypnotic treatment could bring improvement.
September 11, 1889. First Sitting. Bernheim’s method [of hypnosis]
used, in order to induce lethargy as quickly as possible.
 Krafft-Ebing, Psychopathia Sexualis — 189
Suggestions:—
1. I abhor onanism, and will not masturbate again.
2. I regard the inclinations for men disgusting,—horrible; and I shall
never think men handsome and enticing.
3. Women alone I find enticing. Once a week I shall cohabit with
pleasure and power.
The patient received these suggestions, and repeated them in a drawl-
ing tone.
The sittings took place every second day. After the fifteenth, it was pos-
sible to induce the somnambulistic stage of hypnosis with any post-hyp-
notic suggestions desired.
The patient improved morally and mentally, but symptoms of cerebral
neurasthenia troubled him still, and, now and then, dreams of men
occurred; and there were, also, in the waking state, inclinations towards
men, which depressed him exceedingly. . . .
December 9, 1889, patient again came for treatment. Of late he had
had lascivious dreams of men twice, but had experienced no inclination
toward men in the waking state. He had also resisted the impulse to mas-
turbate, though, while living alone in the country, he had had no opportu-
nity for coitus. He had inclinations only for the opposite sex, and, as a rule,
dreamed only of females. Returned to the city, he had indulged in coitus
with pleasure. The patient felt himself morally rehabilitated, being almost
free from neurasthenic symptoms; and, after three more hypnotic sittings,
he declared himself perfectly well, and confident that he would not relapse.
Such a relapse occurred, however, in September, 1890, when, after over-
exertion on an excursion into the mountains, and emotional strain with
want of opportunity for coitus, he again became neurasthenic.
Again he had dreams of men, and felt drawn toward attractive male
forms; he masturbated many times, and, after returning to the city, found
no real pleasure in coitus. By means of anti-neurasthenic treatment and
hypnosis, it was possible to restore the previous condition.
In the course of the years 1890 and 1891 the patient now and then
had contrary sexual feelings and dreams, but only when, as a result of emo-
tional strain or excesses, his neurosis re-appeared. At such time satisfac-
tion in coitus was wanting. He would then find it necessary to undergo a
few hypnotic sittings, in order to restore his equilibrium—always with
success.
190 — Brain Science, Nerves, Clinical Psychiatry
At the end of 1891 the patient pointed with satisfaction to the fact that,
since treatment, he had been able to avoid masturbation and male-inter-
course, and had regained his self-confidence and self-respect.

Case 137. “I was born in 1858, out of wedlock. It was only late that I was
able to trace my obscure origin, and obtain knowledge of my parents; and
this knowledge is, unfortunately, very obscure and imperfect. My father and
mother were cousins. My father died three years ago. He later married, and,
as far as I know, had several healthy children.
“I do not think that my father had contrary sexual feelings. Without
knowing him as my father, I often saw him when I was a child. He was a
powerful, masculine man. As for the rest, it is said that, at the time of my
birth, or before, he was sexually ill.
“ . . . I think I may say that my vita sexualis was really first awakened
after I had been seduced into mutual masturbation, in my thirteenth year,
by a room-mate at the Institute. At that time ejaculation did not take place,
but first about a year later. Nevertheless, I gave myself up to the vice of
onanism passionately. At this time, however, the first signs of homo-sexual
inclination were manifested. Youthful, powerful men, market-helpers,
workmen, and soldiers took possession of my dreams and played an impor-
tant role in my fancy while masturbating.
“ . . . When, at the age of fourteen, I went to H., I lost sight of my lover
and seducer. He was some years older than I, and was an official; and, in
this capacity, when I was nineteen, I again met him once on the railway. We
immediately cut the journey short, and lodged together, attempting mutual
pederasty; but, on account of pain, immissio was not successful. We
amused ourselves in mutual onanism. In H. I had sexual intercourse with
two fellow-students, but this intercourse was confined to frequent mutual
onanism, owing to the fact that they were not inclined to pederasty. . . .
“With my sojourn here, my vita sexualis has undergone a complete
change. I have learned how easy it is to find persons who, partly for money
and partly for desire, yield to our inclinations. I have also not been spared
annoying experiences with cheats. Until the end of the last year (since
then, owing to fear of venereal infection, I have not gone beyond mutual
masturbation), I enjoyed male-love to the full extent, particularly in passive
pederasty. I have never practiced active pederasty, because I have found no
one able to endure the pain.
 Krafft-Ebing, Psychopathia Sexualis — 191
“Generally, I seek my lovers among cavalrymen and sailors, and even-
tually, among workmen, especially butchers and smiths. Robust forms,
with healthy facial complexions, attract me especially. Leathern riding-
trousers have a particular charm for me. I have no partiality for kissing and
the like. I also love large, hard, and calloused hands.
“I do not wish to leave unmentioned that, under certain circumstances,
I have great control of myself.
“ . . . Until my thirty-eighth year I had not a clear understanding of my
condition. I always thought that, by early and frequent masturbation, I had
become averse to women, and hoped always that, when the right woman
came, I should be able to abandon onanism and find pleasure in her. Here
it was that I first came to fully understand my condition, after making the
acquaintance of others suffering and feeling like myself. At first I was fright-
ened; later I came to look upon my fate as something not dependent on
myself. Too, I made no further effort to resist temptation.
“Two or three weeks ago ‘Psychopathia Sexualis’ fell into my hands.
The work has made an unexpectedly deep impression on me. At first I read
the work with an interest that was undoubtedly lascivious. The description
of the cultivation of mujerados, for example, excited me uncommonly.* The
thought of a young, powerful man being emasculated in this manner, in
order, later, to be used for pederasty by a whole tribe of wild, powerful, and
sensual Indians, so excited me that I masturbated five times during the next
two days, fancying myself such a presumptive mujerado. The farther I read
in the book, however, the more I saw its moral earnestness; the more I felt
disgust with my condition; and the more I saw that I must do everything,

*Editor’s note: George Miller Beard, for instance, describes mujerados as a group of
men among the Pueblo Indians with “protuberant abdomens, well-developed mam-
mary glands, rounded and soft limbs, shrunken genital organs, high, thin, cracked
voices, and pubes devoid of hair. . . . In order to make a Mujerado a very strong man
is selected; masturbation is performed upon him many times a day; he has to ride
almost continuously on horseback without saddle. By this process the genital
organs become much excited, and seminal losses are produced; the nutrition of the
organs is interfered with; they grow smaller and weaker, and, in time, desire and
power cease; then follow the changes in character, the desire to dress like a woman
and to engage in feminine occupations, just as with the Scythians; courage and man-
hood are lost; wives and children, for those who have them, pass from their con-
trol.” George M. Beard, Sexual Neurasthenia (Nervous Exhaustion): Its Hygiene,
Causes, Symptoms, and Treatment, with a Chapter on Diet for the Nervous (New York:
E. B. Treat, 1886), 100–101.
192 — Brain Science, Nerves, Clinical Psychiatry
if it were possible, to bring about a change in my condition. When I had
finished the book, I was determined to seek assistance from its author.
“The reading of this work had an undoubted effect. Since then I have
masturbated only twice, and have practiced onanism with cavalrymen only
twice. In every instance I have had really less pleasure and satisfaction than
before, and I always have the feeling: ‘Ah, if I could only be free from it!’
Nevertheless, I confess that, even now, in the society of handsome soldiers,
I immediately have erection.
“In conclusion, I may add that, in spite of, or, perhaps, on account of,
onanism, I have never had pollutions. The ejaculation of semen, which usu-
ally consists of only a few drops, and it has always been so, takes place only
after prolonged friction. If, for any reason, I have not masturbated for a long
time, the ejaculation takes place quickly, and is more abundant. About
twelve years ago Hansen tried in vain to hypnotize me.” *
In the spring of 1891 the writer of the foregoing autobiography visited
me, with the declaration that he could live no longer in his condition; that
he looked to hypnotic treatment as the only hope of salvation, for he had
not strength enough to resist his impulse to masturbation and satisfaction
with persons of his own sex. He felt like a pariah; like an unnatural man;
like one outside the laws of nature and society, and in danger of criminal
prosecution. He felt moral repugnance when he performed the act with a
man, but yet the sight of any handsome soldier actually electrified him.
For years he had not had the slightest sympathy with women, not even
mentally.
The patient looked to be exactly the person, physically and mentally,
described by himself in his autobiography. His head was exquisitely hydro-
cephalic, and also plagiocephalic. At first attempts at hypnosis met with dif-
ficulties. Only by Braid’s method, with the help of a little chloroform, was
deep lethargy attained at the third sitting.† From that time simply looking
at a shining object was sufficient. The suggestions consisted of the com-
mand to avoid masturbation, the removal of homosexual feelings, and the

*Editor’s note: He is referring here to Carl Hansen (1833–1897), a Danish hypno-

tist who performed on stage in Vienna around this time.
†
Editor’s note: Braid’s method refers to the method of hypnosis developed by James
Braid (1795–1860), the Scottish surgeon who first coined the term hypnosis. Braid
emphasized the importance of relaxation, directed attention, and suggestion in a
successful hypnosis.
 Charcot, “A Tuesday Lesson: Hysteroepilepsy” — 193
assurance that the patient would have inclination for women and be virile,
and have pleasure only in hetero-sexual intercourse. Masturbation was in-
dulged in but once; after the eighth sitting the patient dreamed of a woman.
When, after the fourteenth sitting, the patient had to return, on
account of pressing business, he declared that he was quite free from any
inclination to masturbate and to indulge in male-love, but that he was by
no means absolutely free from his partiality for men. He felt returning inter-
est in the female sex, and hoped to be freed finally from his unhappy con-
dition by continuance of the treatment.

From Richard von Krafft-Ebing, Psychopathia Sexualis (Philadelphia: F. A. Davis,

1892), 319–321, 330–308.

Jean-Martin Charcot
(1825–1893)

“A Tuesday Lesson: Hysteroepilepsy”

(1888)

During the last quarter of the nineteenth century, the French neu-
rologist Jean-Martin Charcot was among the most acclaimed experts
in the world on hysteria. Conducting research and teaching at the
famous Salpêtrière Hospital in Paris (1862–1893), Charcot used a
novel combination of clinical observation, pathological anatomy, and
photography to analyze hysterical episodes, breaking them down
into discrete stages in order to enable more accurate diagnosis. By
1883, Charcot had turned the Salpêtrière into a hub for the study
of hysteria: of the some five hundred women admitted to the hospi-
tal at that time, around 20 percent were diagnosed with hysterical
symptoms. Charcot treated these mostly working-class patients
with a regimen that included the use of ovarian compressor belts,
hypnotism, and electrotherapy.
Charcot was a renowned self-promoter. His fame grew especially
after he introduced a set of weekly public lectures, attended by
194 — Brain Science, Nerves, Clinical Psychiatry
students, physicians, researchers, artists, and writers from all over
Europe. On Fridays, he gave carefully prepared presentations,
employing diagrams, drawings, art, and even costumed patients to
make his points. The Tuesday Lessons were reserved for more
impromptu discussion of cases and for interviews with newly admit-
ted patients. In both settings, Charcot typically illustrated his the-
ses by using hypnotism to induce hysterical symptoms in his
patients. The dramatic features of the lectures did not escape the
notice of contemporaries, and, as the excerpt below shows, critics
questioned whether Charcot’s patients were merely getting caught
up in the medical theater being staged.

(A female patient on a stretcher is brought into the amphitheater.)

charcot: Here is a patient whom you saw last Friday. After a fall she
developed a lower extremity contracture with a deformity of her right foot.
Nothing is more frequent in hysterics than posttraumatic contractures.
What could one make of such a case? I told you last time how important it
is to treat and cure these contractures as soon as they appear. But now here
we have an exception to this rule, and we have waited and watched this
woman three or four days without interfering. I told you why we did this—
with cases like this woman’s, you may, in fact, be able to treat this through
provoking a second sort of attack. Often with such attacks, a change occurs
in the patient and a contracture that seemed permanently fixed before can
completely disappear. You may say to me, “Isn’t there something immoral
about waiting and provoking such crises?” Surely not, if one can offer a
treatment for a disorder that otherwise has no cure.
And I have shown you how there is a parallel relationship between
transient hysteric attacks and the forms of hysteria like this one that last
longer, five or six months. Often, those patients with contractures are not
those who have fleeting hysteric attacks and vice versa. It is because of this
doctrine, so soundly described by Dr. Pitres, that we can make use of hys-
terogenic points to provoke a transient attack as a form of therapy in the
treatment of static hysteric signs. Now, this patient will be used for demon-
stration. I will tell you, however, that although I am practically certain of
the outcome of this experiment, man is less predictable than machinery,
and I will not be totally surprised if, in fact, we do not succeed. I have also
 Charcot, “A Tuesday Lesson: Hysteroepilepsy” — 195

A Clinical Lesson with Charcot at the Salpêtrière 1887, by Andre Brouillet

(1857–1914). This famous portrait depicts the neurologist Jean-Martin
Charcot during one of his public lectures. Here he discusses the case of a
patient (Blanche Wittmann), who has just been hypnotized by his assistant
Joseph Babinski. Hopital Neurologique, Lyon, France. © Erich Lessing/Art
Resource, NY.

heard that animal experiments performed before an audience often given

different results from those seen in the laboratory. This may be the case
here, since this is, in fact, a comparable clinical experiment. If we do not get
the desired result, it still will be a significant lesson for you.
This patient has a hysterogenic point on her back, another under her
left breast, and a third on her leg. We will focus on this latter one. If the
attack proceeds as I believe it will, I will want you to focus on all its phases.
This is not an easy task, and it took me many years to analyze the phe-
nomena you will see. I first came to the Salpêtrière 15 or 20 years ago and
inherited the well-run service of Dr. Delasiauve. From my first days I wit-
nessed these hysteroepileptic attacks, and was very circumspect in making
my early diagnoses. I said to myself, “How can it be that such events are not
described in the textbooks? How should I go about describing these events
from my first-hand experience?” I was befuddled as I looked at such patients,
and this impotence greatly irritated me. Then one day, when reflecting over
all these patients as a group, I was struck with a sort of intuition about
196 — Brain Science, Nerves, Clinical Psychiatry
them. I again said to myself, “Something about them makes them all the
same.” Indeed we have a particular disease before us—primary hysteria
beginning with an epilepticlike attack that resembles so closely real epilepsy
that it may be called hysteroepilepsy, even though it has nothing at all to do
with true epilepsy. The epileptoid phase can be divided into a tonic and
clonic portion. Then, after a brief respite, the phase of exotic movements
begins, under one or two predominant forms, either vocalizations or
extreme opisthotonus (arc en cercle). Then, the third phase supercedes, and
suddenly the patient looks ahead at an imaginary image—indeed a halluci-
nation, which will vary according to the setting. The patient may look with
great fear or with joy, depending on what she sees. You saw this in a woman
the other day when I touched her abdomen in the ovarian region. She rose
from her bed, hurried into the corner, and said the most distressing things.
But I want you to appreciate especially the unfolding of an attack. I tell
you all this beforehand so that you can mark each phase, since they are hard
to appreciate without preparation. Importantly, the attack is not a series of
individual small attacks, but a single event that unrolls sequentially. I use
here the method of describing an archetype with the most complex and
fully developed features described. This system is essential for all neuro-
logic diagnosis; one must learn to identify the archetype. The epileptoid
phase can be lacking and the attack begin with the movement phase, either
vocalizations or back arching. Sometimes the movements never appear, and
one only has hallucinations. There are as many as 20 variations, but if you
have the key to the archetype, you immediately focus on the disease at hand
and can say with confidence that in spite of the many possible variations,
all these cases represent the same disorder. So, here we have this contracted
foot that reportedly cannot be reduced either during the day or night. I have
not specifically examined it at all times, but I surmise that this is in fact
true. We are not dealing here with simulation, one of the greatest obstacles
to neurology. (The intern touches the hysterogenic point under the left breast.
Immediately, the attack begins).

charcot: Now, here we have the epileptoid phase. Remember this

sequence—epileptoid phase, arched back, then vocalizations. The arched
back that you now see is rather pronounced. Now here comes the phase of
emotional outbursts, which fuses with the back arching, and now there is
a contracture phase. Such contractures can persist occasionally, and if this
 Charcot, “A Tuesday Lesson: Hysteroepilepsy” — 197
occurs in our patient, we will hardly have helped her. Now the epileptoid
period starts again. Focus your attention this time on the two distinct
epileptoid movement phases—first, the tonic, then the clonic. Note how
this resembles true epilepsy. Now let us see if she is ovarian. (The intern
comes forwards and presses the ovarian region).
charcot: Do this in a real epileptic and nothing will happen, showing
you immediately the difference between epilepsy and hysteroepilepsy. In
contrast to this situation, epilepsy has no direct link with the ovary. See
how the attack is momentarily suspended by abdominal compression. Is it
true that ovarian compression actually aborts the attack? This maneuver is
contested in a number of textbooks, where the authors act as if they know
what they are talking about. In both England and Germany there are some
people who say they have never seen ovarian compression work, but these
same people are those who are all too eager to generalize from their very
limited experience. In that the phenomenon has been unequivocally
demonstrated to occur in Paris, I find it only reasonable to believe it also
occurs elsewhere.
Now we will release the compression, and you will see how the attack
promptly recommences. Here comes the epileptoid phase again. Often out-
side of France, epileptoid behavior is still called epilepsy. I disagree with
such terminology and distinctly calls this hysteroepilepsy or hysteria
major. Here now comes the arched back. Note the consistent pattern,
always predictable and regular. . . .
Let us press again on the hysterogenic point. Here we go again. Occa-
sionally subjects even bite their tongues, but this would be rare. Look at the
arched back, which is so well described in the textbooks.
patient: Mother, I am frightened.
charcot: Note the emotional outburst. If we let things go unabated,
we will soon return to the epileptoid behavior. Now we have a bit of tran-
quility, or resolution, followed by a type of static contracted posture. I con-
sider this latter deformity as an accessory phenomenon to the basic attack.
(The patient cries again: “Oh! Mother.”)
charcot: Again, note these screams. You could say it is a lot of noise
over nothing. True epilepsy is much more serious and also much more quiet.
I do not know what will be the final outcome for this woman’s con-
tractures, but I am glad to have been able to show you a rather typical
198 — Brain Science, Nerves, Clinical Psychiatry
attack. Let us review for emphasis: an epileptoid phase with two parts, tonic
and iconic, followed by a phase of exotic movements, and then a phase of
high emotional pitch, which, in this patient, is sad. All these are then fol-
lowed by these strange contorted postures.
This patient was just a minute ago quite stiff, which is unusual. Most
patients look quite natural and assume realistic poses during all of this. A
final phase is quite rare and not seen in this patient—a period of delirium.
Here, after the phase of affective change, the cycle starts over and may
continue for several days. Ovarian compression is effective only for some
patients—these are called ovarian subjects. Clearly, all subjects are not
ovarian. I can only emphasize again my stand on this, even though others
have misquoted my opinions. From such misquotes, I have been said to
advocate surgical operations in the form of ovarian ablation for hys-
teroepilepsy, such as are performed in America. What I have said is still
true; there are certain patients who have ovarian tenderness and in such
patients, ovarian compression can stop an individual attack, although not
the disease. When I say stop an attack, I mean you can provide your patient
with a respite. We will place around this patient’s abdomen a compression
belt, and she will temporarily be controlled. But some day she will have to
remove it—she can’t wear it forever, and she may well start her spells all
over again. Ovarian compression is a preventative method and also a means
to assure temporary peace. But I emphasize again, it is not a cure. Nor is
ovarian resection. Do not be fooled, the ovary is not the only spot that can
be compressed for effective control. . . .
It would seem by some accounts that hysteroepilepsy exists only in
France; in fact, it has been said that it exists only at the Salpêtrière, as if I
have created this condition by my own willpower. What a marvel this
would be if I could, in fact, fabricate illnesses according to my whims or fan-
tasies. But in fact all I am is a photographer. I describe what I see. And it is
all too easy to show you that such phenomena have indeed occurred out-
side the walls of the Salpêtrière. First, the descriptions of possessed victims
from the Middle Ages are full of similar descriptions. Dr. Richer,* in his
monograph, showed how in the fifteenth century, the same syndrome

*Translator’s note: Paul Richer was both artist and neurologist and always a close
collaborator of Charcot. The reference is to Richer’s Clinical Studies on Hystero-
epilepsy (with 105 drawings and 9 engravings) (Paris: Delahaye et LeCrosnier,
1881).
 Charcot, “A Tuesday Lesson: Hysteroepilepsy” — 199
occurred just as it does today. Furthermore, I have received numerous con-
temporary personal reports, primarily from North American sources, that
have no inherent relationship to the Salpêtrière. These letters were inspired
by my reports of hysteroepilepsy and demonstrate that elsewhere cases
exist that are exactly comparable to our cases here.
In England there is a highly distinguished physician, Dr. Gowers, who
does not believe my descriptions. He sees things quite differently. In his
treatise on epilepsy he uses the term “hysteroid conditions” after epilepsy.
He considers the first “epileptic phase” that we have seen today as true
epilepsy and agrees that all the subsequent phenomena you have witnessed
occur, but he calls them postictal. Why? Because the patient’s crisis always
starts with what appears to be epileptic. We are seeing the same things and
calling it by different names. I maintain that the sequence of events is a
single process and is fixed in stepwise relationship of each phase. It forms
an entity called hysteroepilepsy, and I will not be convinced otherwise.
Prior to my becoming director of this service, my predecessors intro-
duced terminology to distinguish patients with these mixed attacks
(attaques à crises mixtes) of hysteroepilepsy from those with distinct attacks
of alternating hysteria and true epilepsy (attaques à crises separées). What
does this latter term mean?
Let us take a look at another patient. (Another woman comes in.) From
time to time, this woman has various attacks. She is hysterical but also truly
epileptic. By this I mean she has two distinct and essentially different dis-
eases, both belonging to the same general family as would be, for instance,
gout and rheumatism occurring in the same patient. Now the two condi-
tions are separate and remain so throughout the patient’s life. They do not
fuse or evolve one into the other. Let us not incorrectly create a Darwinism
of such events. The pivotal feature in the doctrine of evolution is time,
meaning multiple generations, and when I speak of two separate disorders,
I speak of them in the context of one person’s brief life.
In the case of separated crises, you have first an attack of hysteroepilepsy
and then an attack of real epilepsy. In such a case, after a hysterical out-
burst, a patient may be found to have bitten her tongue. When the staff
gets the patient back to bed and examines here, they will say, “No, she has
had a real seizure” if she bit her tongue, and “Yes, it was a hysterical spell”
if there was no tongue biting. The point here is that the two are entirely dif-
ferent types of events, although they may occur in the same patient. If one
200 — Brain Science, Nerves, Clinical Psychiatry
reports that a patient had a real seizure, this behavior is taken seriously. If
the same patient is said to have a hysterical fit, even lasting six days, there
would be no major concern. If she has a real seizure, she could progress to
status epilepticus, so the physician is immediately notified. The temperature
could rise. Life itself would be at stake. Therefore, the distinction between
the two is paramount. In hysteroepileptic patients with a known hystero-
genic point, you could compress it, not only experimentally, to induce hys-
terical attacks, but more importantly, to stop them; whereas, if the attack is
really a seizure, such compression will serve absolutely no purpose.
I will add that whereas potassium bromide has a palliative effect on true
epilepsy, it will not help hysteroepileptic events. You can give tons of it
without changing these patients. Primary hysteria is not epilepsy. Only in
the patient’s family tree will the two link together. By this I mean that a
hysteroepileptic parent can have a child with true epilepsy and vice versa.
But to be truthful, they could just as well give birth to manics or other chil-
dren with forms of psychosis as well. I have told you before that the neu-
rologic tree has many branches, and each one bears different fruits.

From Jean-Martin Charcot, Charcot the Clinician: The Tuesday Lessons, translated by
Christopher G. Goetz (New York: Raven, 1987), 102–109. With permission of
Christopher G. Goetz.

Emil Kraepelin
(1856–1926)

“About the Surveillance Ward at the

Heidelberg Clinic for Lunatics”
(1895)

Emil Kraepelin’s influence on modern psychiatry is difficult to over-

estimate. His insistence that psychiatric disorders be understood in
terms of their symptoms and course (not their etiology), his effort
to identify statistical regularities in symptoms, his use of experi-
 Kraepelin, “About the Surveillance Ward” — 201
mental techniques, and his development of a clinical picture for
dementia praecox (schizophrenia) and cyclothymia (manic depres-
sion, or bipolar disorder) set in motion an agenda pursued by clini-
cal psychiatry up to this very day. Assuming the position of director
of the psychiatric clinic at the University of Heidelberg in 1891, he
turned the facility into a site that combined teaching, research, and
treatment.
The excerpt here describes his refinement of the surveillance
ward at the Heidelberg clinic. Surveillance wards—large rooms that
allowed staff to keep patients under “constant observation”—were
first developed in Germany in the 1880s. These “scientific observa-
tories,” as one psychiatrist described them, constituted a new kind
of institutional space, designed specifically to address the needs of a
new urban, university-based psychiatry. Note the prevalence and
use of psychoactive drugs on the ward.

I had been convinced of the need for a sufficiently large surveillance ward
since my first year working at the Heidelberg clinic. Because of constant
overcrowding in those rooms originally earmarked for the use of the sur-
veillance ward, I had already considered it necessary to plan on a transfer
from those wards to the adjoining and far more spacious ward for the semi-
calm. With this revolution, I managed to completely get rid of the semi-
calm ward during the day, in order to gain more space for scientific research
rooms. Those rooms made available from the earlier surveillance ward were
now only used as sleeping halls, whereas the small number of “semi-calm”
patients were distributed among the three remaining wards—the surveil-
lance ward and those for calm and agitated patients. . . .
At the outset, it must be granted that the described layout of the sur-
veillance ward, as it once was, has certain significant disadvantages. It is cer-
tainly correct to insist that, above all else, a surveillance ward allow a clear
view so that an unobstructed surveillance of all residents is possible. Admit-
tedly in our clinic, rooms A–D are connected to one another via wide door
openings, but it is not possible for a person to responsibly keep watch over
more than at most two rooms at the same time. Fortunately such an awk-
ward observation of each individual patient in the entire ward is not alto-
gether necessary, as will become evident, so that practical operations have
202 — Brain Science, Nerves, Clinical Psychiatry
not been hindered in any noticeable way by the inadequate layout of the
ward. In fact, it has proven to be an estimable advantage that, in some direc-
tions, the peculiar arrangement of rooms allows for a more effective segre-
gation on the surveillance ward of individual patients with different
classifications.
In order to get an exact picture of all relevant circumstances [on the
ward], special questionnaires were filled out for 250 days—from 3 January
to 9 September 1893 (in addition to the standard daily reports following
the Munich model). These contained, first of all, a record of the names of
all the patients who found themselves on the surveillance ward from day to
day, followed by a brief report on the apparent reason for their stay. Atten-
tion was also paid to those patients transferred to the surveillance ward
only at night. In addition, the names of all patients in beds in other wards
(for whatever reason) were also included. Furthermore, all tranquilizer and
sleeping medication doses were continuously recorded, along with the par-
ticular reasons and the level of success. The duration of and reasons for
every individual isolation were also entered. Finally, a survey of the distri-
bution of patients in different wards during the day and at night was con-
ducted on a regular basis. The 250 questionnaires for men and women that
were collected were each put into 5 consecutive groupings, each covering
50 days, in order to be able to track changes in ward operations during the
entire period of observation.
The daily average occupancy of the clinic during the entire time was
109.34 patients, of which 62.54 were in the male and 46.80 in the female
ward. Of this total number, an average of 46.65 patients (42.66 percent)
found themselves in both wards, 23.08 (36.89 percent) of the men and
23.57 (50.37 percent) of the women. The surveillance ward for men
accommodated, then, over one-third of the total number, while the one for
women an average of one-half. The difference derives in part from the larger
frequency of depressive and agitated conditions among the women. Among
the daily residents of the surveillance ward, depressed and agitated patients
made up 12.04—around 19 percent—of the total number of male occu-
pants, while for women the number was 15.48, i.e., no less than 33 percent
of all female patients. In addition, it should naturally be noted that the spa-
tial expansion of the surveillance ward made increasing the number of beds
for more than 25 additional patients very difficult and, thus, the impact of
the changing number of total residents was felt more on the remaining
 Kraepelin, “About the Surveillance Ward” — 203
wards than on the surveillance ward. During the entire observation period,
the latter was filled almost to capacity on both sides of the clinic. The total
amount of floor space in the patient rooms of the surveillance ward was
around 231 square meters. Thus, on the basis of average occupancy, each
patient had approximately 10 square meters of floor space or, since the
height was 3.8 meters, 38 cubic meters of air space. . . .
The reasons why individual patients were placed in the surveillance
ward, according to the survey report, were varied. In the case of the first
group of patients, indications primarily involved somatic issues; the task of
the surveillance ward was “care” for the patient in the stricter sense of the
term. This includes those with genuine physical ailments of all kinds,
namely those sick with fever. These are joined by the lame, paralytics in
advanced stages, apoplectics, as well as those who are unhelpful and bedrid-
den because of age, weakness, or other frailty or otherwise place greater
demands on staff. Also the unhygienic should be counted here, especially
those largely falling under the latter category of care. At any rate, there are
also some feeble-minded, catatonics, and similar types who are not frail, but
nevertheless, because of their lack of hygiene, require the better care pro-
vided by the surveillance ward. Finally, the physical condition of those who
refuse food is a primary reason for accommodation on the surveillance
ward. All patients who do not eat enough food are looked after in bed and
are placed under constant supervision.
Those refusing food constitute the second main group of surveillance
ward residents—those patients who suffer from severe depressive condi-
tions. The primary task of the surveillance ward here consists of monitor-
ing. It is well known that these patients provided the initial impetus for the
construction of surveillance wards. All anxious and sad patients are part of
this group, as long as there is concern about suicidal tendencies; also those
patients who appear to be a danger to themselves for other reasons and,
finally, those in a daze or stupor who do not fall under the first grouping,
since one often has to reckon with sudden, unexpected, dangerous behav-
ior on their part.
Besides monitoring, the surveillance ward offers these patients the pos-
sibility of lengthy bed rest, something that must be considered a form of
therapy. This is perhaps the case to a greater extent for another group of
patients whom we primarily try to treat on the surveillance ward: the
frenetic. The majority of these are manic patients, especially periodic and
204 — Brain Science, Nerves, Clinical Psychiatry
circular forms, as well as some paralytics and hebephrenics. These patients,
like those who are anxiously agitated and demanding, can be supported
most easily in bed on the surveillance ward and, in this manner, be satis-
factorily influenced.
Alongside the three main groups of patients discussed so far, there is a
small number of persons on the surveillance ward who are best accommo-
dated here for a variety of reasons. The common goal is generally a more
precise observation of the patients. Here it would be worth mentioning the
new admissions about whom there are questions as to which of the above
groups they might belong, prisoners under investigation, morphine and
cocaine addicts, epileptics requiring special and on-going examinations
(body weight, urine samples, digestion tests, etc), and, finally, some
patients requiring a certain measure of segregation while being monitored
because of particular sensitivities, deformities, or infectious or disgusting
ailments. . . .
To get a full picture of operations on the surveillance ward, it is neces-
sary to know the extent to which narcotics and sleeping medications have
been given. If we count all those medications for which we methodically
distribute a daily dose of an opium or bromine treatment, a daily average of
7.16 men and 7.36 women received tranquilizers or sleeping medications.
Due to the varying occupancy levels on both wards, the percentage for men
would be 11.45 percent and 15.74 percent for the women. The higher fig-
ure for women can be explained easily, being due to the fact that dispro-
portionately more agitated patients were registered among their ranks. On
average, among the men, 8.5 percent of day shift and 6.1 percent of night
shift patients were counted as agitated; for the women, the figures were
24.4 percent for the day shift and 8.3 percent for the night shift. The large
discrepancy during the day shift moved toward parity during the night shift,
something that perhaps speaks to the fact that the agitation of women is
determined to a greater degree by external influences than is the case with
the men. Also the greater frequency of periodic manic and circular forms of
milder agitation among the women vis a vis the more severe paralytic,
epileptic, and alcoholic frenetic conditions found among the men plays a
certain role here.
Considering the significantly higher number of agitated patients among
the women, the amount of sleep medications and tranquilizers adminis-
tered on the male side appears disproportionately too large. The cause of
 Kraepelin, “About the Surveillance Ward” — 205
this most probably lies in the exceptionally high number of patients. The
male ward can normally accommodate around 55 patients; nevertheless, on
average there were 62.5 patients here, and, one day, the number reached
70. Thus, it appeared impossible to adequately separate the disruptive
patients from the others, so we had to rely more frequently on sleeping
medications than would have been necessary under better circumstances,
in order to establish some quiet during the night. Most often, sleeping med-
ications were naturally administered on the surveillance ward, since it was
here that those patients resided who most needed sedation both for them-
selves and for their surrounding environment. This situation is made very
clear in the following summary, which cites the percentage of patients in
the entire clinic and the percentage of patients on the surveillance ward
who, on average, received daily sleeping medication. Opium treatment for
anxious patients is not included here.
Time Periods (I–V)
I II III IV V

Men
Sleeping Medication Total (pct) 7.42 8.50 10.60 12.39 9.85
On the Surveillance Ward 12.71 14.48 18.52 23.08 15.56
Percentage of Agitated Patients 6.24 7.08 10.16 9.43 9.59

Women
Sleeping Medication Total (pct) 12.12 9.15 11.56 10.82 14.05
On the Surveillance Ward 14.59 11.63 13.06 12.11 15.20
Percentage of Agitated Patients 22.15 20.09 21.26 24.15 34.70

Without question, the proportion of patients who received sleeping

medication is greater on the surveillance ward than throughout the entire
clinic, but this difference is everywhere more pronounced on the male side.
From this, we can conclude that the administration of sleeping medication
to men was essentially rooted in the effort to be able to care for disruptive
patients with the least amount of injury to their neighbors on the surveil-
lance ward; whereas for the women, the need for sleeping medication
appears hardly lower in the other wards and accords with the large number
of agitated elements in general. . . .
206 — Brain Science, Nerves, Clinical Psychiatry
The following table provides information about the types of medication
administered, in which, though, a number of medications (duboisin, chlo-
ral hydrate, chloral morphine) are not cited. Alcohol that is used more fre-
quently as a sleep aid in cases of mild anxiety and fatigue psychosis is also
not taken into account, while habitual consumption without medical justi-
fication was completely eliminated. The figures refer to daily doses; when it
comes to bromine and opium, the unit is generally the sum of a number of
separate doses during the day.

Trional Sulfate Hyoscine Morphine Opium Bromine

Men 347 721 20 — 420 279

Women 228 511 206 74 509 312

Among men, actual sleeping medications, trional and sulfate, predomi-

nate, which can be explained by the need to establish quiet during the night
in over-crowded wards. By contrast, among the women, the experimental
administration of the quick-acting and powerful narcotics hyoscine and
morphine was noticeably common. In these cases, then, it involved com-
bating sudden bouts of agitation as effectively as possible. The correspon-
dence of this result with our earlier table is self-evident, though it should
not be overlooked that in the selection of medication, the personal inclina-
tions and experiences of the ward physician naturally plays a very impor-
tant role. The more substantial use of (almost always) methodically
administered opium and bromine on women is obviously tied to the previ-
ously established greater frequency of depressive conditions among the
female sex.

From Emil Kraepelin, “Über die Wachabteilung der Heidelberger Irrenklinik,” All-
gemeine Zeitschrift für Psychiatrie und psychisch-gerichtliche Medizin 51 (1895): 1–21.
Translated by Greg Eghigian.
 Freud, “The Origin and Development of Psychoanalysis” — 207

Sigmund Freud
(1856–1939)

“The Origin and Development

of Psychoanalysis”
(1910)

Sigmund Freud studied neurology at the University of Vienna. Soon

after receiving his medical degree, in 1885, he went to Paris to
observe the famous Jean-Martin Charcot. Leaving Paris in 1886,
Freud returned to Vienna with an interest in the psychological ori-
gins of hysteria. He soon established his own private practice and a
partnership with his colleague Josef Breuer (1842–1925). Together
the two men developed the outlines of a new approach to psychiatric
disorders, stressing the roles of memory, trauma, and therapeutic
talk. Freud and Breuer soon parted ways, and Freud went on to elab-
orate his own school of thought—psychoanalysis.
In 1909, Freud came to the United States—his only visit—at the
invitation of the president of Clark University, the psychologist
G. Stanley Hall. There, Freud gave a series of lectures intended to
introduce Americans to the new field. The warm reception he
received was a harbinger of things to come, as the United States
proved to be far more receptive to psychoanalytic thinking than did
his home continent of Europe.

First Lecture

Ladies and Gentlemen: It is a new and somewhat embarrassing experience

for me to appear as lecturer before students of the New World. I assume
that I owe this honor to the association of my name with the theme of
psychoanalysis, and consequently it is of psychoanalysis that I shall aim to
speak. I shall attempt to give you in very brief form an historical survey of
the origin and further development of this new method of research and
cure.
208 — Brain Science, Nerves, Clinical Psychiatry
Granted that it is a merit to have created psychoanalysis, it is not my
merit. I was a student, busy with the passing of my last examinations, when
another physician of Vienna, Dr. Joseph Breuer, made the first application
of this method to the case of an hysterical girl (1880–82). We must now
examine the history of this case and its treatment, which can be found in
detail in Studien über Hysterie, later published by Dr. Breuer and myself.
But first one word. I have noticed, with considerable satisfaction, that
the majority of my hearers do not belong to the medical profession. Now
do not fear that a medical education is necessary to follow what I shall have
to say. We shall now accompany the doctors a little way, but soon we shall
take leave of them and follow Dr. Breuer on a way which is quite his own.
Dr. Breuer’s patient was a girl of twenty-one, of a high degree of intel-
ligence. She had developed in the course of her two years’ illness a series of
physical and mental disturbances which well deserved to be taken seriously.
She had a severe paralysis of both right extremities, with anasthesia, and at
times the same affection of the members of the left side of the body; dis-
turbance of eye-movements, and much impairment of vision; difficulty in
maintaining the position of the head; an intense Tussis nervosa; nausea
when she attempted to take nourishment; and at one time for several weeks
a loss of the power to drink, in spite of tormenting thirst. Her power of
speech was also diminished, and this progressed so far that she could nei-
ther speak nor understand her mother tongue; and, finally, she was subject
to states of “absence,” of confusion, delirium, alteration of her whole per-
sonality. These states will later claim our attention.
When one hears of such a case, one does not need to be a physician to
incline to the opinion that we are concerned here with a serious injury,
probably of the brain, for which there is little hope of cure and which will
probably lead to the early death of the patient. The doctors will tell us, how-
ever, that in one type of cases with just as unfavorable symptoms, another,
far more favorable, opinion is justified. When one finds such a series of
symptoms in the case of a young girl, whose vital organs (heart, kidneys)
are shown by objective tests to be normal, but who has suffered from strong
emotional disturbances, and when the symptoms differ in certain finer
characteristics from what one might logically expect, in a case like this the
doctors are not too much disturbed. They consider that there is present no
organic lesion of the brain, but that enigmatical state, known since the time
of the Greek physicians as hysteria, which can simulate a whole series of
 Freud, “The Origin and Development of Psychoanalysis” — 209
symptoms of various diseases. They consider in such a case that the life of
the patient is not in danger and that a restoration to health will probably
come about of itself. The differentiation of such an hysteria from a severe
organic lesion is not always very easy. But we do not need to know how a
differential diagnosis of this kind is made; you may be sure that the case of
Breuer’s patient was such that no skillful physician could fail to diagnose
an hysteria. We may also add a word here from the history of the case. The
illness first appeared while the patient was caring for her father, whom she
tenderly loved, during the severe illness which led to his death, a task which
she was compelled to abandon because she herself fell ill.
So far it has seemed I best to go with the doctors, but we shall soon part
company with them. You must not think that the outlook of a patient with
regard to medical aid is essentially bettered when the diagnosis points to
hysteria rather than to organic disease of the brain. Against the serious
brain diseases medical skill is in most cases powerless, but also in the case
of hysterical affections the doctor can do nothing. He must leave it to
benign nature, when and how his hopeful prognosis will be realized.
Accordingly, with the recognition of the disease as hysteria, little is changed
in the situation of the patient, but there is a great change in the attitude of
the doctor. We can observe that he acts quite differently toward hystericals
than toward patients suffering from organic diseases. He will not bring the
same interest to the former as to the latter, since their suffering is much less
serious and yet seems to set up the claim to be valued just as seriously.
But there is another motive in this action. The physician, who through
his studies has learned so much that is hidden from the laity, can realize in
his thought the causes and alterations of the brain disorders in patients suf-
fering from apoplexy or dementia, a representation which must be right up
to a certain point, for by it he is enabled to understand the nature of each
symptom. But before the details of hysterical symptoms, all his knowledge,
his anatomical-physiological and pathological education, desert him. He
cannot understand hysteria. He is in the same position before it as the lay-
man. And that is not agreeable to any one, who is in the habit of setting
such a high valuation upon his knowledge. Hystericals, accordingly, tend to
lose his sympathy; he considers them persons who overstep the laws of his
science, as the orthodox regard heretics; he ascribes to them all possible
evils, blames them for exaggeration and intentional deceit, “simulation,”
and he punishes them by withdrawing his interest.
210 — Brain Science, Nerves, Clinical Psychiatry
Now Dr. Breuer did not deserve this reproach in this case; he gave his
patient sympathy and interest, although at first he did not understand how
to help her. Probably this was easier for him on account of those superior
qualities of the patient’s mind and character, to which he bears witness in
his account of the case.
His sympathetic observation soon found the means which made the
first help possible. It had been noticed that the patient, in her states of
“absence,” of psychic alteration, usually mumbled over several words to
herself. These seemed to spring from associations with which her thoughts
were busy. The doctor, who was able to get these words, put her in a sort
of hypnosis and repeated them to her over and over, in order to bring up
any associations that they might have. The patient yielded to his suggestion
and reproduced for him those psychic creations which controlled her
thoughts during her “absences,” and which betrayed themselves in these
single spoken words. These were fancies, deeply sad, often poetically beau-
tiful, day dreams, we might call them, which commonly took as their start-
ing point the situation of a girl beside the sick-bed of her father. Whenever
she had related a number of such fancies, she was, as it were, freed and
restored to her normal mental life. This state of health would last for sev-
eral hours, and then give place on the next day to a new “absence,” which
was removed in the same way by relating the newly-created fancies. It was
impossible not to get the impression that the psychic alteration which was
expressed in the “absence” was a consequence of the excitations originat-
ing from these intensely emotional fancy-images. The patient herself, who
at this time of her illness strangely enough understood and spoke only Eng-
lish, gave this new kind of treatment the name “talking cure,” or jokingly
designated it as “chimney sweeping.”
The doctor soon hit upon the fact that through such cleansing of the
soul more could be accomplished than a temporary removal of the con-
stantly recurring mental “clouds.” Symptoms of the disease would disap-
pear when in hypnosis the patient could be made to remember the situation
and the associative connections under which they first appeared, provided
free vent was given to the emotions which they aroused. “There was in the
summer a time of intense heat, and the patient had suffered very much from
thirst; for, without any apparent reason, she had suddenly become unable
to drink. She would take a glass of water in her hand, but as soon as it
touched her lips she would push it away as though suffering from hydro-
 Freud, “The Origin and Development of Psychoanalysis” — 211
phobia. Obviously for these few seconds she was in her absent state. She
ate only fruit, melons and the like, in order to relieve this tormenting thirst.
When this had been going on about six weeks, she was talking one day in
hypnosis about her English governess, whom she disliked, and finally told,
with every sign of disgust, how she had come into the room of the gov-
erness, and how that lady’s little dog, that she abhorred, had drunk out of
a glass. Out of respect for the conventions the patient had remained silent.
Now, after she had given energetic expression to her restrained anger, she
asked for a drink, drank a large quantity of water without trouble, and woke
from hypnosis with the glass at her lips. The symptom thereupon vanished
permanently.”
Permit me to dwell for a moment on this experience. No one had ever
cured an hysterical symptom by such means before, or had come so near
understanding its cause. This would be a pregnant discovery if the expec-
tation could be confirmed that still other, perhaps the majority of symp-
toms, originated in this way and could be removed by the same method.
Breuer spared no pains to convince himself of this and investigated the
pathogenesis of the other more serious symptoms in a more orderly way.
Such was indeed the case; almost all the symptoms originated in exactly
this way, as remnants, as precipitates, if you like, of affectively-toned expe-
riences, which for that reason we later called “psychic traumata.” The
nature of the symptoms became clear through their relation to the scene
which caused them. They were, to use the technical term, “determined”
(determiniert) by the scene whose memory traces they embodied, and so
could no longer be described as arbitrary or enigmatical functions of the
neurosis.
Only one variation from what might be expected must be mentioned.
It was not always a single experience which occasioned the symptom, but
usually several, perhaps many similar, repeated traumata cooperated in this
effect. It was necessary to repeat the whole series of pathogenic memories
in chronological sequence, and of course in reverse order, the last first and
the first last. It was quite impossible to reach the first and often most essen-
tial trauma directly, without first clearing away those coming later.
You will of course want to hear me speak of other examples of the cau-
sation of hysterical symptoms beside this of inability to drink on account of
the disgust caused by the dog drinking from the glass. I must, however, if I
hold to my programme, limit myself to very few examples. Breuer relates,
212 — Brain Science, Nerves, Clinical Psychiatry
for instance, that his patient’s visual disturbances could be traced back to
external causes, in the following way. “The patient, with tears in her eyes,
was sitting by the sick-bed when her father suddenly asked her what time
it was. She could not see distinctly, strained her eyes to see, brought the
watch near her eyes so that the dial seemed very large (macropia and stra-
bismus conv.), or else she tried hard to suppress her tears, so that the sick
man might not see them.”
All the pathogenic impressions sprang from the time when she shared
in the care of her sick father. “Once she was watching at night in the great-
est anxiety for the patient, who was in a high fever, and in suspense, for a
surgeon was expected from Vienna, to operate on the patient. Her mother
had gone out for a little while, and Anna sat by the sick-bed, her right arm
hanging over the back of her chair. She fell into a revery [sic] and saw a
black snake emerge, as it were, from the wall and approach the sick man as
though to bite him. (It is very probable that several snakes had actually
been seen in the meadow behind the house, that she had already been
frightened by them, and that these former experiences furnished the mate-
rial for the hallucination). She tried to drive off the creature, but was as
though paralyzed. Her right arm, which was hanging over the back of the
chair, had ‘gone to sleep,’ become anasthetic [sic] and paretic, and as she
was looking at it, the fingers changed into little snakes with deaths-heads.
(The nails). Probably she attempted to drive away the snake with her par-
alyzed right hand, and so the anasthesia [sic] and paralysis of this member
formed associations with the snake hallucination. When this had vanished,
she tried in her anguish to speak, but could not. She could not express her-
self in any language, until finally she thought of the words of an English
nursery song, and thereafter she could think and speak only in this lan-
guage.” When the memory of this scene was revived in hypnosis the paral-
ysis of the right arm, which had existed since the beginning of the illness,
was cured and the treatment ended.
When, a number of years later, I began to use Breuer’s researches and
treatment on my own patients, my experiences completely coincided with
his. In the case of a woman of about forty, there was a tic, a peculiar smack-
ing noise which manifested itself whenever she was laboring under any
excitement, without any obvious cause. It had its origin in two experiences
which had this common element, that she attempted to make no noise, but
that by a sort of counter-will this noise broke the stillness. On the first
 Freud, “The Origin and Development of Psychoanalysis” — 213
occasion, she had finally after much trouble put her sick child to sleep, and
she tried to be very quiet so as not to awaken it. On the second occasion,
during a ride with both her children in a thunderstorm the horses took
fright, and she carefully avoided any noise for fear of frightening them still
more. I give this example instead of many others which are cited in the
“Studien über Hysterie.”
Ladies and gentlemen, if you will permit me to generalize, as is indis-
pensable in so brief a presentation, we may express our results up to this
point in the formula: Our hysterical patients suffer from reminiscences.
Their symptoms are the remnants and the memory symbols of certain
(traumatic) experiences.
A comparison with other memory symbols from other sources will per-
haps enable us better to understand this symbolism. The memorials and
monuments with which we adorn our great cities, are also such memory
symbols. If you walk through London you will find before one of the great-
est railway stations of the city a richly decorated Gothic pillar”—“Charing
Cross.” One of the old Plantagenet kings, in the thirteenth century, caused
the body of his beloved queen Eleanor to be borne to Westminster, and had
Gothic crosses erected at each of the stations where the coffin was set
down. Charing Cross is the last of these monuments, which preserve the
memory of this sad journey. In another part of the city, you will see a high
pillar of more modern construction, which is merely called “the monu-
ment.” This is in memory of the great fire which broke out in the neigh-
borhood in the year 1666, and destroyed a great part of the city. These
monuments are memory symbols like the hysterical symptoms; so far the
comparison seems justified. But what would you say to a Londoner who to-
day stood sadly before the monument to the funeral of Queen Eleanor,
instead of going about his business with the haste engendered by modern
industrial conditions, or rejoicing with the young queen of his own heart?
Or to another, who before the “Monument” bemoaned the burning of his
loved native city, which long since has arisen again so much more splendid
than before?
Now hystericals and all neurotics behave like these two unpractical
Londoners, not only in that they remember the painful experiences of the
distant past, but because they are still strongly affected by them. They can-
not escape from the past and neglect present reality in its favor. This fixa-
tion of the mental life on the pathogenic traumata is an essential, and
214 — Brain Science, Nerves, Clinical Psychiatry
practically a most significant characteristic of the neurosis. I will willingly
concede the objection which you are probably formulating, as you think
over the history of Breuer’s patient. All her traumata originated at the time
when she was caring for her sick father, and her symptoms could only be
regarded as memory symbols of his sickness and death. They corresponded
to mourning, and a fixation on thoughts of the dead so short a time after
death is certainly not pathological, but rather corresponds to normal emo-
tional behavior. I concede this: there is nothing abnormal in the fixation of
feeling on the trauma shown by Breuer’s patient. But in other cases, like
that of the tic that I have mentioned, the occasions for which lay ten and
fifteen years back, the characteristic of this abnormal clinging to the past is
very clear, and Breuer’s patient would probably have developed it, if she had
not come under the “cathartic treatment” such a short time after the trau-
matic experiences and the beginning of the disease.
We have so far only explained the relation of the hysterical symptoms
to the life history of the patient; now by considering two further moments
which Breuer observed, we may get a hint as to the processes of the begin-
ning of the illness and those of the cure. With regard to the first, it is espe-
cially to be noted that Breuer’s patient in almost all pathogenic situations
had to suppress a strong excitement, instead of giving vent to it by appro-
priate words and deeds. In the little experience with her governess’ dog, she
suppressed, through regard for the conventions, all manifestations of her
very intense disgust. While she was seated by her father’s sick bed, she was
careful to betray nothing of her anxiety and her painful depression to the
patient. When, later, she reproduced the same scene before the physician,
the emotion which she had suppressed on the occurrence of the scene
burst out with especial strength, as though it had been pent up all along.
The symptom which had been caused by that scene reached its greatest
intensity while the doctor was striving to revive the memory of the scene,
and vanished after it had been fully laid bare. On the other hand, experience
shows that if the patient is reproducing the traumatic scene to the physi-
cian, the process has no curative effect if, by some peculiar chance, there is
no development of emotion. It is apparently these emotional processes
upon which the illness of the patient and the restoration to health are
dependent. We feel justified in regarding “emotion” as a quantity which
may become increased, derived and displaced. So we are forced to the con-
clusion that the patient fell ill because the emotion developed in the patho-
 Freud, “The Origin and Development of Psychoanalysis” — 215
genic situation was prevented from escaping normally, and that the essence
of the sickness lies in the fact that these “imprisoned” (dingeklemmt) emo-
tions undergo a series of abnormal changes. In part they are preserved as a
lasting charge and as a source of constant disturbance in psychical life; in
part they undergo a change into unusual bodily innervations and inhibi-
tions, which present themselves as the physical symptoms of the case. We
have coined the name “hysterical conversion” for the latter process. Part of
our mental energy is, under normal conditions, conducted off by way of
physical innervation and gives what we call “the expression of emotions.”
Hysterical conversion exaggerates this part of the course of a mental
process which is emotionally colored; it corresponds to a far more intense
emotional expression, which finds outlet by new paths. If a stream flows in
two channels, an overflow of one will take place as soon as the current in
the other meets with an obstacle.
You see that we are in a fair way to arrive at a purely psychological the-
ory of hysteria, in which we assign the first rank to the affective processes.
A second observation of Breuer compels us to ascribe to the altered condi-
tion of consciousness a great part in determining the characteristics of the
disease. His patient showed many sorts of mental states, conditions of
“absence,” confusion and alteration of character, besides her normal state.
In her normal state she was entirely ignorant of the pathogenic scenes and
of their connection with her symptoms. She had forgotten those scenes, or
at any rate had dissociated them from their pathogenic connection. When
the patient was hypnotized, it was possible, after considerable difficulty, to
recall those scenes to her memory, and by this means of recall the symp-
toms were removed. It would have been extremely perplexing to know how
to interpret this fact, if hypnotic practice and experiments had not pointed
out the way. Through the study of hypnotic phenomena, the conception,
strange though it was at first, has become familiar, that in one and the same
individual several mental groupings are possible, which may remain rela-
tively independent of each other, “know nothing” of each other, and which
may cause a splitting of consciousness along lines which they lay down.
Cases of such a sort, known as “double personality” (“double conscience”),
occasionally appear spontaneously. If in such a division of personality con-
sciousness remains constantly bound up with one of the two states, this is
called the conscious mental state, and the other the unconscious. In the
well-known phenomena of so-called post hypnotic suggestion, in which a
216 — Brain Science, Nerves, Clinical Psychiatry
command given in hypnosis is later executed in the normal state as though
by an imperative suggestion, we have an excellent basis for understanding
how the unconscious state can influence the conscious, although the latter
is ignorant of the existence of the former. In the same way it is quite possi-
ble to explain the facts in hysterical cases. Breuer came to the conclusion
that the hysterical symptoms originated in such peculiar mental states,
which he called “hypnoidal states” (hypnoide Zustände). Experiences of an
emotional nature, which occur during such hypnoidal states easily become
pathogenic, since such states do not present the conditions for a normal
draining off of the emotion of the exciting processes. And as a result there
arises a peculiar product of this exciting process, that is, the symptom, and
this is projected like a foreign body into the normal state. The latter has,
then, no conception of the significance of the hypnoidal pathogenic situa-
tion. Where a symptom arises, we also find an amnesia, a memory gap, and
the filling of this gap includes the removal of the conditions under which
the symptom originated.
I am afraid that this portion of my treatment will not seem very clear,
but you must remember that we are dealing here with new and difficult
views, which perhaps could not be made much clearer. This all goes to
show that our knowledge in this field is not yet very far advanced. Breuer’s
idea of the hypnoidal states has, moreover, been shown to be superfluous
and a hindrance to further investigation, and has been dropped from pres-
ent conceptions of psychoanalysis. Later I shall at least suggest what other
influences and processes have been disclosed besides that of the hypnoidal
states, to which Breuer limited the causal moment.
You have probably also felt, and rightly, that Breuer’s investigations
gave you only a very incomplete theory and insufficient explanation of the
phenomena which we have observed. But complete theories do not fall
from Heaven, and you would have had still greater reason to be distrustful,
had any one offered you at the beginning of his observations a well-rounded
theory, without any gaps; such a theory could only be the child of his spec-
ulations and not the fruit of an unprejudiced investigation of the facts.

Second Lecture

Ladies and Gentlemen: At about the same time that Breuer was using the
“talking-cure” with his patient, M. Charcot began in Paris, with the hys-
 Freud, “The Origin and Development of Psychoanalysis” — 217
tericals of the Salpêtrière, those researches which were to lead to a new
understanding of the disease. These results were, however, not yet known
in Vienna. But when about ten years later Breuer and I published our pre-
liminary communication on the psychic mechanism of hysterical phenom-
ena, which grew out of the cathartic treatment of Breuer’s first patient, we
were both of us under the spell of Charcot’s investigations. We made the
pathogenic experiences of our patients, which acted as psychic traumata,
equivalent to those physical traumata whose influence on hysterical paral-
yses Charcot had determined; and Breuer’s hypothesis of hypnoidal states
is itself only an echo of the fact that Charcot had artificially reproduced
those traumatic paralyses in hypnosis.
The great French observer, whose student I was during the years
1885–86, had no natural bent for creating psychological theories. His stu-
dent, P. Janet, was the first to attempt to penetrate more deeply into the
psychic processes of hysteria, and we followed his example, when we made
the mental splitting and the dissociation of personality the central points of
our theory.* Janet propounds a theory of hysteria which draws upon the
principal theories of heredity and degeneration which are current in France.
According to his view hysteria is a form of degenerative alteration of the
nervous system, manifesting itself in a congenital “weakness” of the func-
tion of psychic synthesis. The hysterical patient is from the start incapable
of correlating and unifying the manifold of his mental processes, and so
there arises the tendency to mental dissociation. If you will permit me to
use a banal but clear illustration, Janet’s hysterical reminds one of a weak
woman who has been shopping, and is now on her way home, laden with
packages and bundles of every description. She cannot manage the whole
lot with her two arms and her ten fingers, and soon she drops one. When
she stoops to pick this up, another breaks loose, and so it goes on.
Now it does not agree very well, with this assumed mental weakness of
hystericals, that there can be observed in hysterical cases, besides the phe-
nomena of lessened functioning, examples of a partial increase of functional
capacity, as a sort of compensation. At the time when Breuer’s patient had
forgotten her mother-tongue and all other languages save English, her con-
trol of English attained such a level that if a German book was put before

*Editor’s note: Freud here refers to Pierre Janet (1859–1947), a French neurologist
and psychologist who wrote on hysteria and hypnosis.
218 — Brain Science, Nerves, Clinical Psychiatry
her she could give a fluent, perfect translation of its contents at sight.
When later I undertook to continue on my own account the investigations
begun by Breuer, I soon came to another view of the origin of hysterical dis-
sociation (or splitting of consciousness). It was inevitable that my views
should diverge widely and radically, for my point of departure was not, like
that of Janet, laboratory researches, but attempts at therapy. Above every-
thing else, it was practical needs that urged me on. The cathartic treatment,
as Breuer had made use of it, presupposed that the patient should be put in
deep hypnosis, for only in hypnosis was available the knowledge of his
pathogenic associations, which were unknown to him in his normal state.
Now hypnosis, as a fanciful, and so to speak, mystical, aid, I soon came to
dislike; and when I discovered that, in spite of all my efforts, I could not
hypnotize by any means all of my patients, I resolved to give up hypnotism
and to make the cathartic method independent of it.
Since I could not alter the psychic state of most of my patients at my
wish, I directed my efforts to working with them in their normal state. This
seems at first sight to be a particularly senseless and aimless undertaking.
The problem was this: to find out something from the patient that the doc-
tor did not know and the patient himself did not know. How could one
hope to make such a method succeed? The memory of a very noteworthy
and instructive proceeding came to my aid, which I had seen in Bernheim’s
clinic at Nancy. Bernheim showed us that persons put in a condition of
hypnotic somnambulism, and subjected to all sorts of experiences, had only
apparently lost the memory of those somnambulic experiences, and that
their memory of them could be awakened even in the normal state.* If he
asked them about their experiences during somnambulism, they said at first
that they did not remember, but if he persisted, urged, assured them that
they did know, then every time the forgotten memory came back.
Accordingly I did this with my patients. When I had reached in my
procedure with them a point at which they declared that they knew noth-
ing more, I would assure them that they did know, that they must just tell
it out, and I would venture the assertion that the memory which would
emerge at the moment that I laid my hand on the patient’s forehead would
be the right one. In this way I succeeded, without hypnosis, in learning

*Editor’s note: Hippolyte Bernheim (1840–1919) was known for his contention
that hypnosis was little more than a form of ritualized suggestion.
 Freud, “The Origin and Development of Psychoanalysis” — 219
from the patient all that was necessary for a construction of the connection
between the forgotten pathogenic scenes and the symptoms which they
had left behind. This was a troublesome and in its length an exhausting
proceeding, and did not lend itself to a finished technique. But I did not give
it up without drawing definite conclusions from the data which I had
gained. I had substantiated the fact that the forgotten memories were not
lost. They were in the possession of the patient, ready to emerge and form
associations with his other mental content, but hindered from becoming
conscious, and forced to remain in the unconscious by some sort of a force.
The existence of this force could be assumed with certainty, for in attempt-
ing to drag up the unconscious memories into the consciousness of the
patient, in opposition to this force, one got the sensation of his own per-
sonal effort striving to overcome it. One could get an idea of this force,
which maintained the pathological situation, from the resistance of the
patient.
It is on this idea of resistance that I based my theory of the psychic
processes of hystericals. It had been found that in order to cure the patient
it was necessary that this force should be overcome. Now with the mecha-
nism of the cure as a starting point, quite a definite theory could be con-
structed. These same forces, which in the present situation as resistances
opposed the emergence of the forgotten ideas into consciousness, must
themselves have caused the forgetting, and repressed from consciousness
the pathogenic experiences. I called this hypothetical process “repression”
(Verdrängung), and considered that it was proved by the undeniable exis-
tence of resistance.
But now the question arose: what were those forces, and what were the
conditions of this repression, in which we were now able to recognize the
pathogenic mechanism of hysteria? A comparative study of the pathogenic
situations, which the cathartic treatment has made possible, allows us to
answer this question. In all those experiences, it had happened that a wish
had been aroused, which was in sharp opposition to the other desires of the
individual, and was not capable of being reconciled with the ethical, aes-
thetic and personal pretensions of the patient’s personality. There had been
a short conflict, and the end of this inner struggle was the repression of the
idea which presented itself to consciousness as the bearer of this irrecon-
cilable wish. This was, then, repressed from consciousness and forgotten.
The incompatibility of the idea in question with the “ego” of the patient
220 — Brain Science, Nerves, Clinical Psychiatry
was the motive of the repression, the ethical and other pretensions of the
individual were the repressing forces. The presence of the incompatible
wish, or the duration of the conflict, had given rise to a high degree of men-
tal pain; this pain was avoided by the repression. This latter process is evi-
dently in such a case a device for the protection of the personality.
I will not multiply examples, but will give you the history of a single one
of my cases, in which the conditions and the utility of the repression
process stand out clearly enough. Of course for my purpose I must abridge
the history of the case and omit many valuable theoretical considerations.
It is that of a young girl, who was deeply attached to her father, who had
died a short time before, and in whose care she had shared—a situation
analogous to that of Breuer’s patient. When her older sister married, the
girl grew to feel a peculiar sympathy for her new brother-in-law, which eas-
ily passed with her for family tenderness. This sister soon fell ill and died,
while the patient and her mother were away. The absent ones were hastily
recalled, without being told fully of the painful situation. As the girl stood
by the bedside of her dead sister, for one short moment there surged up in
her mind an idea, which might be framed in these words: “Now he is free
and can marry me.” We may be sure that this idea, which betrayed to her
consciousness her intense love for her brother-in-law, of which she had not
been conscious, was the next moment consigned to repression by her
revolted feelings. The girl fell ill with severe hysterical symptoms, and,
when I came to treat the case, it appeared that she had entirely forgotten
that scene at her sister’s bedside and the unnatural, egoistic desire which
had arisen in her. She remembered it during the treatment, reproduced the
pathogenic moment with every sign of intense emotional excitement, and
was cured by this treatment.
Perhaps I can make the process of repression and its necessary relation
to the resistance of the patient, more concrete by a rough illustration,
which I will derive from our present situation.
Suppose that here in this hall and in this audience, whose exemplary
stillness and attention I cannot sufficiently commend, there is an individual
who is creating a disturbance, and, by his ill-bred laughing, talking, by
scraping his feet, distracts my attention from my task. I explain that I can-
not go on with my lecture under these conditions, and thereupon several
strong men among you get up, and, after a short struggle, eject the dis-
turber of the peace from the hall. He is now “repressed,” and I can continue
 Freud, “The Origin and Development of Psychoanalysis” — 221
my lecture. But in order that the disturbance may not be repeated, in case
the man who has just been thrown out attempts to force his way back into
the room, the gentlemen who have executed my suggestion take their
chairs to the door and establish themselves there as a “resistance,” to keep
up the repression. Now, if you transfer both locations to the psyche, calling
this “consciousness,” and the outside the “unconscious,” you have a toler-
ably good illustration of the process of repression.
We can see now the difference between our theory and that of Janet.
We do not derive the psychic fission from a congenital lack of capacity on
the part of the mental apparatus to synthesize its experiences, but we
explain it dynamically by the conflict of opposing mental forces, we recog-
nize in it the result of an active striving of each mental complex against the
other.
New questions at once arise in great number from our theory. The sit-
uation of psychic conflict is a very frequent one; an attempt of the ego to
defend itself from painful memories can be observed everywhere, and yet
the result is not a mental fission. We cannot avoid the assumption that still
other conditions are necessary, if the conflict is to result in dissociation. I
willingly concede that with the assumption of “repression” we stand, not at
the end, but at the very beginning of a psychological theory. But we can
advance only one step at a time, and the completion of our knowledge must
await further and more thorough work.
Now do not attempt to bring the case of Breuer’s patient under the
point of view of repression. This history cannot be subjected to such an
attempt, for it was gained with the help of hypnotic influence. Only when
hypnosis is excluded can you see the resistances and repressions and get a
correct idea of the pathogenic process. Hypnosis conceals the resistances
and so makes a certain part of the mental field freely accessible. By this
same process the resistances on the borders of this field are heaped up into
a rampart, which makes all beyond inaccessible.
The most valuable things that we have learned from Breuer’s observa-
tions were his conclusions as to the connection of the symptoms with the
pathogenic experiences or psychic traumata, and we must not neglect to
evaluate this result properly from the standpoint of the repression-theory.
It is not at first evident how we can get from the repression to the creation
of the symptoms. Instead of giving a complicated theoretical derivation, I
will return at this point to the illustration which I used to typify repression.
222 — Brain Science, Nerves, Clinical Psychiatry
Remember that with the ejection of the rowdy and the establishment
of the watchers before the door, the affair is not necessarily ended. It may
very well happen that the ejected man, now embittered and quite careless
of consequences, gives us more to do. He is no longer among us, we are free
from his presence, his scornful laugh, his half-audible remarks, but in a cer-
tain sense the repression has miscarried, for he makes a terrible uproar out-
side, and by his outcries and by hammering on the door with his fists
interferes with my lecture more than before. Under these circumstances it
would be hailed with delight if possibly our honored president, Dr. Stanley
Hall, should take upon himself the role of peacemaker and mediator. He
would speak with the rowdy on the outside, and then turn to us with the
recommendation that we let him in again, provided he would guarantee to
behave himself better. On Dr. Hall’s authority we decide to stop the repres-
sion, and now quiet and peace reign again. This is in fact a fairly good pres-
entation of the task devolving upon the physician in the psychoanalytic
therapy of neuroses. To say the same thing more directly: we come to the
conclusion, from working with hysterical patients and other neurotics, that
they have not fully succeeded in repressing the idea to which the incom-
patible wish is attached. They have, indeed, driven it out of consciousness
and out of memory, and apparently saved themselves a great amount of psy-
chic pain, but in the unconscious the suppressed wish still exists, only wait-
ing for its chance to become active, and finally succeeds in sending into
consciousness, instead of the repressed idea, a disguised and unrecogniz-
able surrogate-creation (Ersatzbildung), to which the same painful sensa-
tions associate themselves that the patient thought he was rid of through
his repression. This surrogate of the suppressed idea—the symptom—is
secure against further attacks from the defences of the ego, and instead of a
short conflict there originates now a permanent suffering. We can observe
in the symptom, besides the tokens of its disguise, a remnant of traceable
similarity with the originally repressed idea; the way in which the surrogate
is built up can be discovered during the psychoanalytic treatment of the
patient, and for his cure the symptom must be traced back over the same
route to the repressed idea. If this repressed material is once more made
part of the conscious mental functions—a process which supposes the
overcoming of considerable resistance—the psychic conflict which then
arises, the same which the patient wished to avoid, is made capable of a hap-
pier termination, under the guidance of the physician, than is offered by
 Vincent, “Confessions of an Agoraphobic Victim” — 223
repression. There are several possible suitable decisions which can bring
conflict and neurosis to a happy end; in particular cases the attempt may be
made to combine several of these. Either the personality of the patient may
be convinced that he has been wrong in rejecting the pathogenic wish, and
he may be made to accept it either wholly or in part; or this wish may itself
be directed to a higher goal which is free from objection, by what is called
sublimation (Sublimierung); or the rejection may be recognized as rightly
motivated, and the automatic and therefore insufficient mechanism of
repression be reinforced by the higher, more characteristically human men-
tal faculties: one succeeds in mastering his wishes by conscious thought.
Forgive me if I have not been able to present more clearly these main
points of the treatment which is to-day known as “psychoanalysis.” The
difficulties do not lie merely in the newness of the subject.
Regarding the nature of the unacceptable wishes, which succeed in
making their influence felt out of the unconscious, in spite of repression;
and regarding the question of what subjective and constitutional factors
must be present for such a failure of repression and such a surrogate or
symptom creation to take place, we will speak in later remarks.

From Sigmund Freud, “The Origin and Development of Psychoanalysis,” translated

by Henry W. Chase, American Journal of Psychology 21 (1910): 181–218.

Vincent
“Confessions of an
Agoraphobic Victim”
(1919)

Since ancient times, observers have been aware that some individu-
als are plagued by delusional fears. During the second half of the
nineteenth century, clinicians began to apply the term phobia to a
variety of these extremes forms of anxiety. One of the earliest pho-
bias to draw attention was the fear of certain, typically public, spaces.
In 1871, the Berlin psychiatrist Carl Westphal (1833–1890),
224 — Brain Science, Nerves, Clinical Psychiatry
having encountered patients complaining of an inability to cross or
go down particular streets, dubbed this condition agoraphobia. Like
neurasthenia, agoraphobia appeared to many to be a peculiarly
urban phenomenon, and up until World War I, it was diagnosed
primarily in men. The following autobiographical description of
agoraphobia gives a sense of how the malady was experienced as a
form of nervousness around the turn of the century.

For some time I have been planning to commit to writing personal obser-
vations of my condition, sensations and experiences during a long period of
suffering from a malady which, for lack of a better name, medical men have
termed “Agora-phobia”—fear of an open place.
As I am unacquainted with medical literature I do not know how much
has been written on this subject. Only one case of “confessions” has come
to my notice. Some time ago I read several pamphlets on “Religion and
Medicine”—Emmanuel Church publications—one of which discussed var-
ious “nervous” disorders, among them the “phobias.” In the course of the
discussion there was introduced testimony of a man who had been griev-
ously afflicted with agoraphobia. I devoured these “confessions” with the
greatest avidity. It was the first and only time I had read any testimony of
an individual thus afflicted.
This same pamphlet stated that the man had since become almost
cured. Encouraged by these good tidings I tried to practice mental poise and
tranquility for several weeks. During those few weeks I saw wonderful
improvement in my condition. However, I lapsed gradually into my old habit
of self-neglect, and with this neglect improvement in my health ceased.
The testimony taken from the above mentioned pamphlet leads one to
infer that the affliction came upon the victim rather suddenly, and that the
symptoms of the malady were present only occasionally: namely, when the
man was on certain streets and at definite places on these streets.
If the above inference is correct I have to testify that my case is quite
different. In the first place, my malady came upon me gradually and went
through definite stages of development. Second, I am conscious of my afflic-
tion every minute that I am awake.
I am now in mid-life and I have not seen a well day since I was about
twelve years of age. Before I experienced any of the symptoms of agorapho-
 Vincent, “Confessions of an Agoraphobic Victim” — 225
bia I recall that a strange affliction came over me, an affliction that seemed
to baffle the country doctors who were consulted. I was taken suddenly
with “spells” which lasted about thirty minutes. During these attacks I was
entirely conscious and rational. As I remember the affliction, a sort of chill
came over me—not like an ordinary chill, but a sort of “coldness” that pro-
duced a very unusual sensation, or perhaps, a lack of sensation would
describe it more accurately. I have an impression that the physicians sug-
gested that it might possibly have been due to a temporary stoppage of cir-
culation. At any rate the remedy applied was vigorous rubbing of my body
with rough towels, or with the bare hands by those attending me; some
times, when it was convenient, a hot bath was resorted to; stimulants were
also administered. I was more liable to these attacks during times of excite-
ment. For instance, I recall that one of the worst attacks I ever had came
over me while I was attending the funeral of a relative. When there seemed
to be no outward cause that brought on the attacks, it was noted by my par-
ents that they recurred periodically; I believe it was every fourteen days or
was it eleven days?
My own belief now is that the illness referred to was due to some dis-
order of the nervous system. At any rate, after a few months I outgrew the
tendency. However, I was not a well boy. I was abnormally timid and more
or less melancholy, and was given to worry and brooding.
In this connection I would remark that I was born with an active, nerv-
ous temperament, and was always, as a boy, more or less timid. I was abnor-
mally alert when there was possibility of danger. I remember how I used to
run and leap like a fawn when passing through tall grass and weeds in the
summer time, fearing lest I should encounter snakes, which were rather
common.
When my strange illness came upon me I worried over it, fearing that
I should die in one of the attacks. During this overwrought state of mind I
was much affected by a terrible tragedy which took place in our community.
One of my playmates, a boy about eleven years of age, disappeared one day.
The supposition was that he had fallen into the river and had been
drowned. On this theory, the river was dragged day after day for more than
a week, but no body was discovered. Then the theory was advanced that he
had been kidnapped, or perhaps, he being a venturesome lad, had started
out to “see the world” and had met with foul play. I recall very well how the
entire community was stirred and what effect it had on the boys and girls
226 — Brain Science, Nerves, Clinical Psychiatry
of the village and neighborhood. Finally, one morning in late autumn, the
body of my playmate was found on the bank of the river, at a bend in the
stream just below the village. But he had not been drowned—his throat
was cut from ear to ear. The murder had been committed in a cellar in the
village by a half-crazed woman who had later carried the body, by night, and
placed it on the bank of the river.
This whole affair had a most depressing effect upon me. After that I
almost feared to be alone, was afraid to go to the barn in the day time, and
suffered when put to bed in the dark. Perhaps the worry over my illness,
together with the depressing effect of the tragedy, brought on a severe
attack of nervous dyspepsia. This resulted in malnutrition for my over-
sensitive nervous system which, perhaps, laid the foundation for the
“phobias.”
It was during the months which followed that I remember having expe-
rienced the first symptoms of agoraphobia. There was a high hill not far
from my home in the country where we boys used to coast in the winter
time. One evening while coasting, in company with other boys of the
neighborhood, I experienced an uncomfortable feeling each time we
returned to the top of the hill. It was not a well defined symptom of this
horrible (I use the term deliberately) malady, but later experiences have
taught me that it possessed the unmistakable earmarks. As the months
went by the symptoms developed, with the result that I avoided hill-tops,
so far as possible.
Later, perhaps a year or so, I commenced having a dread of wide fields,
especially when the fields consisted of pasture land and were level, with the
grass cropped short like the grass on a well-kept lawn. I likewise com-
menced to dread high things, and especially to ascend anything high. I even
had a fear of crowds of people, and later of wide streets and parks.
I have outgrown the fear of crowds largely, but an immense building or
a high rocky bluff fills me with dread. However the architecture of the
building has much to do with the sort of sensation produced. Ugly archi-
tecture greatly intensifies the fear.
In this connection I would remark that I have come to wonder if there
is real art in many of the so-called “improvements” in some of our cities,
for, judging from the effect they produce on me, they constitute bad art.
But the one thing that I would make plain is that the malady is always
present. As I write in my study I am painfully conscious of it—in fact, I am
 Vincent, “Confessions of an Agoraphobic Victim” — 227
conscious of it during every hour that I am awake. The fear, intensified,
that comes over me while crossing a wide street is, it seems to me, an out-
cropping of a permanent condition.
It is not pain that I feel, but it seems to me that it is more than a dread.
I am not nervous, as some people whom I know—I mean in the same way,
but it certainly is a case of “nerves.” Let me illustrate:—I enter a home and
sit in an arm-chair chatting with my friend; I soon find myself gripping the
arm of the chair with each hand. My toes curl in my shoes, and there is a
sort of tenseness all over my muscles.
At times my phobias are much more pronounced than at other times.
Sometimes, after a strenuous day, on the following morning, I find myself
almost dreading to walk across a room; at other times I can cross a street
without any pronounced discomfort. Manual labor improves my condition.
Walking and riding horseback are beneficial.
Usually I feel better in the evening than in the morning, partly because
the darkness seems to have a quieting effect upon me. I love a snow storm
a regular blizzard, and feel much less discomfort in going about the town
or riding on a train on such days, probably because one’s view is
obstructed. In fact I welcome stormy days, strange to say, with a zest that
is hard to appreciate; in short, some of the most stormy days of the hard
winters of this region stand out as bright spots in my life. On such days I
make it a point to be out and about the town.
I dread going out on water in a boat, especially if the surface is smooth;
I much prefer to have the waves rolling high. The most restful place in all
the world for me is in a wood, where there is much variety in the trees and
plenty of underbrush, with here and there low hills and little valleys, and
especially along a winding brook. I love “the quiet places by the woods.”
Also the little lakes with their narrow bays and wooded shoreline. I love
quiet, restful landscape. It seems to rest my eyes and soothe my spirit. On
the other hand, let the landscape be bold and rugged and bleak and it strikes
terror to my soul.
I lived in New Haven during four years, while a student at Yale, and
never climbed to the top of East Rock. And the big Green near the univer-
sity always made me very uncomfortable when I looked at it.
I ride a bicycle along streets with comparative comfort where I should
suffer agony were I to walk. In walking I feel less uncomfortable in passing
along the street if I carry a suit-case or traveling-bag—something to grip.
228 — Brain Science, Nerves, Clinical Psychiatry
When I think of the agony which I have experienced for many years I
am astounded at the endurance of the human spirit. Let me illustrate:—I
have such a dread of crossing a long bridge on foot that it would require
more courage for me to walk to the part of my town situated across the river
than it would to face a nest of Boche machine guns. And yet day after day,
month after month, and year after year I have carried in my soul the dread
of such an eventuality.
No one knows the truth about my condition. It is one of the charac-
teristics of the victim of the disease to conceal it most cunningly. I think I
am an honest man in all essential things. My credit is good at the banks.
But I have deliberately told lies to avoid embarrassing situations and have
even changed my plans to have my lies “come true.”
I have never mentioned my condition to a physician. I have passed sev-
eral examinations for life-insurance policies—in fact, have never been
refused a policy by any life insurance company. I eat and sleep well, am
rather strong and wiry physically. My occupation makes heavy demands on
the vitality and entails considerable mental exercise, but I am seldom
unable to take up my duties on account of indisposition. However, in my
own mind I am a nervous wreck, weak, worthless, and unworthy of the
high respect which the community accords me.
In spite of all this I seem to exercise marked power of leadership in my
town, and am known as a public speaker of ability.
Of course, the paramount question with me is: Is there hope of a cure?
Can I ever take my place in the world unhandicapped as other men are, and
enjoy a single day undepressed by dark dread? If I could be as other men, it
seems to me that my usefulness should be increased a hundredfold. Those
who have not been thus afflicted cannot understand just what I mean.
I see a man hobbling past my house on crutches, a cripple for life, and
I actually envy him. At times I would gladly exchange places with the hum-
blest day-laborer who walks unafraid across the public square or saunters
tranquilly over the viaduct on his way home after the day’s work.

From Vincent, “Confessions of an Agoraphobic Victim,” American Journal of Psy-

chology 30 (1919): 295–299.
PART III

The Militant Age

By the turn of the twentieth century, many were questioning the
optimistic outlook that had been voiced in the nineteenth cen-
tury. The precipitous increase in the asylum population, the
apparent emergence of new nervous disorders, and the often dis-
appointing results of therapies led some to fear that, instead of
progressing, public health was on the decline. This perception of
decline encouraged countless public figures to express the view
that Western civilization itself was in a state of degeneration,
caught up in a process of atavistic devolution. The carnage of
World War I (1914–1918), which brought about unprece-
dented loss of life and a mass outbreak of neurotic disorders,
reinforced the conclusion that aggressive scientific, medical, and
political intervention was needed in order to avoid catastrophe.
Between 1914 and 1950, Western publics adjusted themselves
to radically new attitudes toward life and death, health and ill-
ness, pain and suffering.
One of the most popular innovations predated the war.
Eugenics, a field whose name was coined by Francis Galton
(1822–1911), held that various physical and mental attributes
were inherited and that it was incumbent upon society to regu-
late reproduction toward the goal of a healthier population.
Eugenics grew to enjoy broad public support across the political
spectrum, and in the years 1910–1940, the movement inspired
legislation restricting marriage and compelling the sterilization
of those deemed mentally ill or disabled.
It was the Great War, however, that provided the impetus
for more comprehensive change. The conflict proved to be an

229
230 — The Militant Age

economic, political, demographic, and public health disaster for

most every country involved. Around 9 million men were killed
in action, twice that number were wounded, and perhaps another
9–10 million civilians died of famine or disease brought on by
the war. Military hospitals were flooded by soldiers with brain
injuries and neurotic symptoms. Back home, public health offi-
cials reported a rise in nervous complaints among women and
children. With scarce resources being directed primarily at the
war effort, asylum patients proved especially vulnerable. In Ger-
many, around 140,000 of them died between 1914 and 1918,
most from hunger and malnutrition.
There is compelling evidence to indicate that the wartime
emphasis on triage—giving treatment priority to those patients
most likely to survive—moved physicians and policymakers in
central Europe after the war to entertain more radical ideas about
handling mental disorders and disabilities. In 1920, jurist Karl
Binding and psychiatrist Alfred Hoche published Permission for
the Destruction of Life Unworthy of Life, a tract justifying the killing
of what Hoche referred to as “the mentally dead.” To be sure,
this was an extreme and mostly unpopular position, but it
reflected how far some mainstream experts were willing to go in
combating mental disorders.
Many more psychiatrists and neurologists pinned their hopes
for successful cures on biomedical research. One of the great
success stories took place during the first decade of the twenti-
eth century, when scientists discovered that general paresis—an
illness marked by progressive dementia and paralysis and consti-
tuting perhaps 15 percent of the cases in psychiatric hospitals at
the time—was, in fact, the result of syphilis infection earlier in
life. The successful treatment of syphilis with the chemical com-
pound arsphenamine (developed in 1910) seemed to offer the
promise of a bold new future for psychiatric research.
In general, between 1920 and 1950, psychiatry showed
steady interest in finding bodily cures for ostensibly mental dis-
orders. In addition to refinements of earlier regimens, such as
 The Militant Age — 231

sedatives, hydrotherapy, and electrotherapy, there were new,

involved treatments designed to provoke fevers, seizures, or
coma in patients: malaria fever therapy, insulin therapy, and
metrazol therapy. And, of course, there was the lobotomy, a sur-
gical procedure first developed in 1935 in which brain tissue
was deliberately destroyed in order to effect personality changes.
In time, many physicians and the public came to view these
treatments as reckless and unethical. But it needs to be remem-
bered that they were all the products of mainstream scientific
and medical research. After all, the developers of malaria fever
therapy and the lobotomy both received Nobel Prizes for their
work.
That said, the two world wars were bookends for a period of
heroic and, at times, risky medicine. The same was true of pub-
lic policy. Mass death, radical political movements, civil wars,
inflation, unemployment, and austerity led voters and states to
entertain more drastic solutions. Unsurprisingly, perhaps, the
1930s and 1940s were the heyday for eugenic legislation. In Ger-
many, where Adolf Hitler (1889–1945) and the Nazi Party
assumed power in 1933, the government instituted a set of lethal
“racial hygiene” policies. By the end of World War II, the coun-
try had sterilized some three hundred thousand “morally feeble-
minded” individuals and killed around two hundred thousand
“incurable” psychiatric patients, all for the espoused benefit of
the “Aryan race.”
One might term the Nazi episode a politicization of madness
and psychiatry, but this would ignore the fact that insanity and
its treatment have always had political dimensions. Perhaps,
instead, it makes more sense to consider how, in the twentieth
century, policymakers, clinicians, and the lay public became more
self-reflexive, more deliberate in their use of psychiatry and psy-
chotherapy as political tools. This was certainly true in the
Soviet Union, where, beginning in the 1960s, the regime began
diagnosing political dissidents with mental disorders and com-
mitting them to psychiatric facilities. The international public
232 — The Militant Age

outcry prompted clinicians to formulate a universal ethical code

of professional conduct.
Western Europe and the United States also faced criticism
after World War II. The rise of human rights, consumer rights,
disability rights, feminist, and anticolonialism movements
sparked often acerbic debates about psychiatry’s past, present,
and future. This crystallized in the form of the antipsychiatry
movement, an international array of professionals and patients
who questioned medicine’s and the state’s authority to manage
those deemed mentally ill. While some categorically rejected psy-
chiatry’s prerogatives, others sought to reform mental health
care by orienting it around social reintegration. Both “social psy-
chiatry” and “community mental health care” grew out of this
latter impulse. Their goals and methods, reinforced by the devel-
opment of effective new drugs in the 1950s and fiscal concerns
in the 1970s, helped bring about the large-scale emptying of asy-
lums known as deinstitutionalization.
 War and Neurosis

Fritz Kaufmann
(1875–1941)

“The Systematic Cure of Complicated

Psychogenic Motor Disorders
among Soldiers in One Session”
(1916)

Although hysteria was long associated with girls and young women,
French and German clinicians during the last third of the nine-
teenth century began recognizing the increasing prevalence of the
illness in men. In particular, industrial workers of all kinds com-
plained of a variety of nervous ailments for which there was no
apparent organic lesion. In Germany, these functional illnesses
earned the name “traumatic neuroses” and were generally believed
to be caused by jarring shocks to the nervous system. The fact that
large numbers of workmen used this diagnosis to claim social insur-
ance benefits, however, made many policymakers, companies, and
physicians wonder whether these men were simply malingering. By
the early twentieth century, a very lively debate raged not only
about whether the traumatic neuroses were somatic or psychologi-
cal in origin, but also about whether they were the manifestation of
genuine disease or of simply a weak character.

233
234 — War and Neurosis
The issue of male hysteria came to a head during World War I.
In Germany, more than six hundred thousand servicemen were
treated in military hospitals for nervous diseases in the years
1914–1918. By the last year of the war, 5 percent of all hospital
beds in the country were reserved for hysteria cases. The need to
get men treated and returned to service as quickly as possible led cli-
nicians to tinker with traditional treatments. One such treatment
was developed by Fritz Kaufmann, staff physician at the Nervous Ill-
ness Station of the Reserve Infirmary at Ludwigshafen. Before the
war, Kaufmann had experimented on a twenty-year-old hysterical
girl, applying strong electric currents for as long as ten minutes,
combined with verbal suggestion. Her rapid recovery, he claimed,
inspired him to conceive a wartime version he called “the surprise
attack.”

The psychogenic disorders that are coming to our attention among com-
bat soldiers differ in no significant way from the clinical picture that peace-
time practice offers. One particular type has struck me in the evidence I
have encountered, namely, the large number of patients presenting mani-
festations of complicated motor hyperstimulation and breakdown. The
strong tremor is the symptom that virtually all patients with hyperstimu-
lation have in common. One encounters the symptoms isolated in extrem-
ities and linked to contractions on the ends of extremities or throughout
the entire extremity, soon thereafter becoming a general tremor, compli-
cated by ticklike twitches, stutters, pseudospastic paresis, saltatory reflex
spasms, etc.
With my patients, it has appeared irrelevant to the particulars of the
individual case whether it develops acutely after a grenade explosion, or
whether the psyche flees into neurosis after chronic, severe attacks, or
under certain circumstances, following an intermediary influenza or intes-
tinal catarrh, or, finally, whether the psychogenic disorder grafts on to an
organic disorder as an hysterical component and then develops further.
In contrast to many, I consider it necessary to conduct a symptomatic
treatment of the patient with psychogenic stimulations and stoppages as
promptly as possible, as soon as the acute fatigue symptoms—which are
almost never absent among patients in the field—remit. For if it is true that
 Kaufmann, “Cure of Complicated Psychogenic Disorders” — 235
hysteria is not “cured” as soon as the discrete symptoms disappear, it is
also true that there are many patients for whom motor symptoms consti-
tute the only verifiable pathological disturbance, even while there is no sign
of hysterical character or other hysterical stigmata. In such monosympto-
matic cases, one heals the illness by removing the symptoms, even if a cer-
tain “illness inclination” remains. . . .
As far as my own overview of the situation, once they become ill, psy-
chogenic patients, especially those afflicted with the above-cited compli-
cated disorder, are most often sent to standard way stations in a reserve
infirmary on the home front. Depending on the individual treating physi-
cian, they are treated more or less with suggestion. There can be no doubt
that any path to treatment can reach its goal if only it is paved with cor-
rect suggestion. Individuals such as [Max] Nonne in Hamburg achieve
noteworthy success with hypnosis: for the most part, however, their slo-
gan is “convalescence” and “exercise.” I do not fear encountering any
resistance when I contend that a large portion of those patients treated
with convalescence and exercise are eventually released as unfit for service,
many with high pensions, some who still “require outside attention and
care.”
This leads to unhappy consequences for the families; it also leads to the
loss of human labor power for the state; another, not insignificant, conse-
quence is the considerable burden on the military budget. . . .
Since I was unsatisfied with the success of the standard form of sug-
gestive therapy in older cases—and almost all the cases in my unit were of
this kind—I went back to a kind of treatment that I first used in 1903 as
an assistant at the Erbs Clinic. It was common practice in the Erbs Clinic,
as was the case elsewhere, to treat hysterical paralyses with energetic
faradic brushing, often with good success.
On the basis of my successful experience with the surprise attack—
based on and reinforced by Nonne’s announcement that various forms of
psychogenic motor disorders were cured through one hypnotic session—
from the end of 1915, I turned to the surprise attack method that I will
describe in the following.
From everyday experience, we know that innervation that has derailed
because of a mental shock quite frequently is put back on the right track by
a new mental shock. We are now in the position to artificially give patients,
similar to the case I described earlier, just such a shock by using a strong
236 — War and Neurosis
electric current and accompanying this with appropriate verbal suggestion
in the form of orders, all in an effort to cure them.
Our method brings together four components:
1. suggestive preparation
2. application of strong alternating currents with the aid of ample word
suggestion
3. strict conformity to military forms of subordination and the giving
of word suggestions in the form of orders
4. insistent demand for a cure in one session

Re: 1. Suggestive preparation, as I was able to convince myself repeat-

edly (in the case of the psychogenic deaf and dumb), is not essential, but
very desirable. . . . One must emphasize to the patient already during the
days in preparation that the treatment is painful, that, however, he will be
safe and cured by the current in one session.
Re: 2. A mental shock can only be achieved only if severe pain is trig-
gered by the current. At times, especially with those patients who have
never been electrified, one gets by with moderately strong currents, since,
in these cases, the novelty of the sensation is uncommonly suggestive
enough to have its effect. Frequently, however, especially with older cases,
it is necessary to apply strong currents. I mostly use the sinusoidal current
of the Erlanger Pantostat, which was less uncomfortable than the faradic
current, and I eventually combine this with galvanic current, especially in
cases where simultaneous hysterical anasthesia needed to be removed.*
Naturally, one may indiscriminately choose body parts for application. If
these body parts (not to be injured by the current) are the site of the pri-
mary symptom—for instance, the legs in the case of pseudospastic walking
disorders with tremors—these are, of course, electrified. By contrast, for
example, in cases of treating hysterical aphonia, I place the large electrode
plate on the lower spinal column, while the arm is worked on with the Erbs
normal electrode or perhaps the electric brushes, but the larynx is left
untouched. Everything else is left to word suggestion and other suggestive
methods. I let the electric current work for about 2–5 minutes, then exer-
cises are done, followed by more electrification, etc.

*Editor’s note: The Erlanger Pantostat was a portable electrical device commonly
used at the time for this purpose. By 1926, around fifteen thousand had been sold
worldwide.
 Kaufmann, “Cure of Complicated Psychogenic Disorders” — 237
Re: 3. An extraordinarily important aid in this kind of suggestive treat-
ment are the disciplinary qualities of the treating officer: military discipline
demands the most absolute, blind subordination to the orders of the supe-
rior, and this successfully creates the fertile ground for a suggestive proce-
dure. With patients who have psychogenic disorders from intake on, it is necessary
to conform strictly to military protocol, as far that is possible; and then, during
the surprise attack treatment, harshly grab people without appearing bru-
tal, giving instructions in the form of short orders using military commands.
After an electrification, I let those with shakes in the legs or with pseudo-
cerebral ataxia do marching exercises under tough military orders (exactly
like the barrack yard). Those with head tremors have to practice “eyes
right” and “eyes left” orders, etc.
Re: 4. Success can only be achieved with unrelenting persistence in carry-
ing out the treatment. One cannot let up, even if the cure does not happen
after the first few minutes; one cannot tire of constantly emphasizing
that this goal will be reached; one must seek to convince the patient in
every way possible that you are in the position to force your own strong
will upon him. One cannot be afraid of exercising at a slow pace with
spastics, those with tremors, and ataxics. One cannot stop constantly
ordering the aphonic patient after strong electrification to pronounce
“A,” using the aid of energetic gestures (like an orchestra conductor
prompting the fortissimi). In short, you must participate in the treat-
ment with your entire personality. Success is not inevitable, however,
even if on many occasions it emerges after a half hour, an hour, or several hours
of constant effort. . . .
It has proved to be expedient with hard-to-influence patients to take
occasional breaks of a few minutes during the session and to leave the
patients alone for awhile. It is essential to avoid letting those present talk
during the break about things that could distract the patient; rather, it is
advised that you use the break to make comments directed at colleagues
and assistants who are present in order to suggestively influence the
patient. Everything must be employed to have a suggestive impact. Very
often I have encountered the first signs of the return of normal function
right after the breaks. It is well worth emphasizing that, during the treat-
ment, the contact between doctor and patient may not be disturbed by
attempts on the part of those present to rush to the aid of the physician by
word or deed. . . .
238 — War and Neurosis
An additional word about the continued treatment of such patients is
necessary. It appears advisable not to release them immediately during the
first days after the cure, but rather to keep them on hand for several weeks,
in order to be able to offer every possibility of counteracting a potential
relapse. Since the paths for pathological innervation in our patients have
already become established, a relapse is a particular concern when mala vol-
untas plays a role. Thankfully, this is seldom the case. But even patients
with the best intent to be healthy easily relapse, if one does not allow suffi-
cient time for the normal innervation to again generally solidify itself. This
can best take place under the watchful eyes of the physician who achieved
the symptomatic cure. It is likely not necessary to mention that convales-
cence in the infirmary must be undertaken in the proper manner.
These people are no longer suited for combat. After several weeks of
convalescence, for the most part, we have released the patients as fit for
nonactive duty or as infirmary assistants. Unfortunately, we are not yet
mandating catamneses. On the basis of numerous experiences that have
been reported to us by authorities, I have doubts about whether releasing
[these men] as fit for nonactive duty was appropriate; nonactive duty offers
numerous possibilities that can have an adverse effect on the delicate bal-
ance of nerves and cause a relapse. Perhaps it is best to release these people
as fit for work at their former trade.

From Fritz Kaufmann, “Die planmäßige Heilung komplizierter psychogener Bewe-

gungsstörungen bei Soldaten in einer Sitzung,” Münchener medizinische Wochen-
schrift, Feldärztliche Beilage 63 (1916): 802–804. Translated by Greg Eghigian.

W.H.R. Rivers
(1864–1922)

“War Neurosis and Military Training”

(1918)

Like Germany, Great Britain was surprised by the number of men

developing war neurosis or “shell shock,” as it came to be known in
the English-speaking world. During the war, eighty thousand British
 Rivers, “War Neurosis and Military Training” — 239
cases of war neurosis were diagnosed, while after the war, some two
hundred thousand veterans were awarded pensions for war-related
nervous diseases. The physician and anthropologist William Rivers
was among those called on to treat these men during the war. Influ-
enced by evolutionary biology, Rivers had become interested in
nervous illnesses before the war. After the war started, he was
introduced to Freud’s ideas and soon after began applying psycho-
analytic concepts and methods at Craiglockhart War Hospital, near
Edinburgh. There, Rivers treated shell-shocked officers, the most
famous being the war poets Siegfried Sassoon and Wilfred Owen,
by encouraging them to talk about their traumatic memories.

Excluding from the category of neurosis cases of simple exhaustion or con-

cussion and disorders of circulation or digestion due to infection, and
excluding also definite psychoses, cases of war neurosis fall into three main
groups, though intermediate and mixed examples are of frequent occurrence.
The first group comprises cases in which the disorder finds expression
in some definite physical form, such as paralysis, mutism, contracture,
blindness, deafness, or other anaesthesia, or in some convulsive seizure.
The characteristic common to all these symptoms is that they are such as
can be readily produced in hypnotism or other state in which suggestion is
especially potent. . . . In the meantime I shall be content to speak of this
group as hysteria, the term by which it was generally known before the war
and one which, in spite of its unsatisfactory character, is still widely used.
The second group consists of cases in which the disorder shows itself
especially in the lack of physical and mental energy, in disorders of sleep
and of the circulatory, digestive, and urogenital systems. On the mental side
there is usually depression, restlessness, irritability and enfeeblement of
memory, and on the physical side tremors, tics, or disorders of speech. This
group is usually know as neurasthenia in this country, but in this case I
shall anticipate the results of my later discussion and speak of it by the term
anxiety neurosis.
The third group, with which I shall have little to do in this report, is
characterized by the definitely psychical form of its manifestations. This
groups comprises a number of different varieties. In some case the most
obvious symptom is mental instability and restlessness with alternations of
depression and excitement or exaltation, similar to those of manic-depressive
240 — War and Neurosis
insanity. In other cases there are morbid impulses of various kinds, includ-
ing those towards suicide or homicide. In others the chief symptoms are
obsessions or phobias, while others suffer from hallucinations or delusions.
The special feature of all these cases is that the symptoms resemble in kind
those of the definite psychoses, but have neither the severity nor the fixity
which makes the seclusion of the patient or any legal restriction in the man-
agement of his affairs necessary. . . .
[A] brief sketch of the aims and methods of military training has led
me to distinguish three main processes—suggestion, repression, and sub-
limation, while others of less importance in relation to neurosis are habit-
uation and sidetracking. I can now consider how these different factors will
affect officers and men respectively. The heightening of suggestibility,
though probably an inevitable result of any kind of military training, is pre-
eminently one which affects the private soldier. It is the private soldier espe-
cially who is submitted to the commands of others, while the officer is not
only less fully drilled, but the periods in which he is subject to the com-
mands of others are relieved by other periods in which he is the dispenser
of commands and orders.
Sublimation, on the other hand, has more effect on the officer. It is
doubtful how far the honor and welfare of the regiment or other unit
appeals to the private soldier in general, though it is perhaps almost if not
quite as definite among the non-commissioned as among the commissioned
officers of the old army. In the new army, it probably means little or noth-
ing to the ordinary soldier, in whose case any sublimation due to military
training has its source in comradeship or in his feelings of respect and duty
towards his officers, and especially towards either his platoon- or company-
commander. It is because the aggregate with which he acts is composed of
men with whom he has become comrade and friend, that this aggregate
comes to have an influence upon him, while in other cases the relation
towards his officer is more important. In each case, however, the result is
the production of a state of dependence which works in the same direction
as the factor of suggestibility already considered. The point of especial
importance in relation to the incidence of neurosis is that the fact of com-
radeship to some extent, and far more the state of dependence on his offi-
cer, diminish the sentiment of responsibility and thus tend to enhance
suggestibility or, perhaps more correctly, work in the same direction as sug-
gestibility. In the case of the officer, on the other hand, the relation towards
 Rivers, “War Neurosis and Military Training” — 241
his men brings with it responsibilities which are perhaps more potent than
any other element of his experience in determining the form taken by his
nervous disorder, if he should break down. It is these responsibilities and
other conditions associated with them which lead to his being so especially
prone to suffer from the state of anxiety neurosis.
The third main factor, repression, is very important in relation to the
incidence of different forms of neurosis in officers and men. The officer is
driven by his position to repress the expression of emotion far more per-
sistently than the private soldier. It is the special duty of the junior officer
to set an example in this respect to his men, to encourage those who show
signs of giving way. In the proper performance of this duty, it is essential
that the officer shall appear calm and unconcerned in the midst of danger.
The difficulty of keeping up this appearance after long continued strain or
after some shock of warfare has lessened the power of control produces a
state of persistent anxiety which is the most frequent and potent factor in
the production of neurosis, and is especially important in determining the
special form it takes. The private soldier has to think only or chiefly of him-
self; he has not to bear with him continually the thought that the lives of
forty or fifty men are immediately, and of many more remotely, dependent
on his success in controlling any expression of fear or apprehension.
A factor of minor importance, but one which is nevertheless worth
mentioning here, is that the officer is less free to employ the picturesque or
sulphurous language which is one of the instruments by which the Tommy
finds a safety valve for repressed emotion.
The preceding argument has led us to the conclusions that of the three
main agencies upon which the success of military training depends one,
suggestion, is especially potent and prominent in the case of the private,
while the other two, sublimation and repression, have by far the greatest
effect in the case of the officer. One of the chief results of military training
is to increase the suggestibility of the private, and this increased tendency
in one direction is but little counteracted by sublimation or complicated by
the necessity for vigorous repression. The factor of sublimation may even
tend to enhance his dependence and suggestibility. In the case of the offi-
cer, any increase in suggestibility produced by his training is largely com-
pensated by the necessity for individual and spontaneous action, while the
esprit de corps and other means of sublimation only tend in many cases to
heighten his sense of responsibility and thus add still another cause for his
242 — War and Neurosis
anxieties. There are many officers, both commissioned and non-commis-
sioned, to whom the honor of the regiment or battalion is quite as potent
as responsibility for the lives of others in producing the state of anxiety
which forms the essential element in the production of their neurosis.
I have now considered how far the different forms of war neurosis can
be traced to the influence of military training and the nature of military
duties. It is gradually becoming apparent, however, that the conditions of
military training and active service are very far from exhausting the factors
by which war neurosis is produced. A large part, perhaps even a majority of
the prolonged cases of functional nervous disorders which fill our hospitals,
can be traced directly to circumstances which have come into being after
some shock illness, or perhaps only the ordinary process of leave, has
removed the soldier from the actual scene of warfare. I have now to inquire
how far the influence of military training and the nature of military duties
assist in producing the neurosis of the hospital and the home.
Histories of cases of war neurosis show that officers after some shock
or illness suffer for a time from those symptoms which I have ascribed to
suggestion, but whether owing to treatment or spontaneous change, these
symptoms soon disappear. It may be that the failure to be content with a
simple but crude solution of a conflict which satisfies the private soldier is
due to superior education, but the nature of his training and duties also
contribute to this result. If the disability were the unwitting outcome of a
conflict between the instinct of self-preservation and a simple conception of
military duty, it might suffice to be paralyzed or mute, but if the morbid
state depends primarily upon sentiments of responsibility towards his mil-
itary unit or his comrades, such a solution is not likely to satisfy his nature
long. His conflict differs from that of the private soldier in that it is founded
largely upon acquired experience rather than upon instinctive trends. It is
more actively conscious than the process which has produced a paralysis or
mutism. These disabilities fail altogether to touch the special anxieties
which have taken the foremost place in the production of his illness.
In the state of weakened volition produced by shock or exhaustion it
seems to the officer that he will never again be able to exert the vigor of con-
trol and initiative which alone enabled him to maintain the upper hand in
the conflict of the trenches, and with this realization, the former conflict is
replaced by one still more painful and enervating, in which sentiments of
duty struggle ineffectually against a conviction of unfitness.
 Rivers, “War Neurosis and Military Training” — 243
In this conflict military training and duty take a most important place.
There are many officers whose conflict would be solved or would have never
existed, if it were merely a matter of personal safety. It is the knowledge,
born of long experience, that the honor of their military unit and the safety
of their comrades depend on their efficiency which forms in many cases by
far the most potent factor in the production and maintenance of anxiety
states. To the private soldier, devoid of such responsibilities, the mere solic-
itude about his safety forms a less potent motive for conflict, and one which
is more easily solved. Once the disability due to suggestion has disappeared
spontaneously or by treatment, there may be no obvious conflict left. The
instinct of self-preservation, to which his disability has been essentially due,
will of course still be there, ready to reassert itself if the occasion arise, but
any conscious conflict is so readily solved in accordance with obvious stan-
dards of social conduct that there is no opening for the occurrence of any
state of anxiety sufficiently profound to act as the basis of neurosis.
The conclusion reached in the preceding pages is that the private sol-
dier is especially apt to succumb to that form of neurosis which closely
resembles the effects produced by hypnotism or other form of suggestion,
because his military training has been of a kind to enhance his suggestibil-
ity. The officer, on the other hand, is less prone to this form of neurosis and
falls a victim to it only when there is some organic injury which acts as a
continuous source of suggestion. On the other hand the officer is especially
liable to anxiety neurosis, because the nature of his duties especially puts
him into positions of responsibility which produce or accentuate mental
conflicts set up by repression, thus producing states of anxiety, the form
taken by his nervous disorder. . . .

Treatment

If the argument of this report is sound, that the cases of functional nervous
disorder hitherto labeled hysteria are produced by suggestion and depend
on the enhanced suggestibility of the private soldier, it might seem at first
sight the obvious course to make use of this heightened suggestibility in the
treatment, and to use suggestion, either with or without the production of
hypnotic state. If, however, suggestion be used in the ordinary crude way
to remove symptoms, this line of treatment will only tend still further to
heighten the suggestibility of the patient and to increase the tendency to
244 — War and Neurosis
similar disorders whenever he returns to the field. If at the time that the
symptoms are removed suggestions are given against the occurrence of sim-
ilar disabilities in the future, more could be said for this line of treatment,
but this of course would not affect the heightened suggestibility which is
the root of the evil.
The argument of this report points rather to a course in which treat-
ment should be directed to lessen the suggestibility by a process of reedu-
cation. This process should be so designed as to make the soldier
understand the nature of the disorder which has afflicted him. He should
be made to realize the essentially mental basis of his trouble and be thus
put into a position in which, even if the disability recurs, he will not long
be satisfied with it as a solution of the situation. This line of treatment has
the disadvantage that it sometimes succeeds in doing away with the paraly-
sis or other symptoms only to replace the physical disability by a state of
anxiety; but a soldier in whom the conflict between the instinct of self-
preservation and duty is so pronounced as to lead to this result is very
unlikely to show any more real success if treated by suggestion. Here, how-
ever, as in so many other departments of psychotherapy in connection with
the war, we are hampered by our almost total ignorance concerning the
after-history of soldiers who have been subjected to different modes of treat-
ment. It is possible that there are sufferers from suggestion neurosis who
are capable of long and valuable service if the symptoms due to suggestion
are treated by means similar to those by which they have been produced.
In cases of anxiety neurosis the lines of causation considered in this
report offer less help in treatment than in prevention. The knowledge of the
process by which this state has been produced often greatly helps a patient,
especially in removing and diminishing depression, or even shame, conse-
quent upon failure. If he can be brought to see that his illness is the out-
come of definite agencies over which he has had no control, or has been due
to excess rather than defect in certain good qualities, the symptoms may be
greatly relieved and the patient set upon a path which, if the exigencies of
military service allow, may enable him again to perform his military duties.
The knowledge of causation set forth in this report is useful in thus pro-
viding a groundwork for the process of reeducation.

From: W.H.R. Rivers, “War Neurosis and Military Training,” Mental Hygiene 2
(1918): 513–533.
 The New Focus
on the Body

Anonymous
“Autopsychology of the
Manic-Depressive”
(1910)

Hydrotherapy—the use of water to treat ailments—dates back to

ancient times. By the end of the nineteenth century, it was enjoy-
ing something of renaissance and had become a staple in the psy-
chiatric treatment of disorders. Among the most prominent
applications of hydrotherapy at the time were two regimens. The
first was the continuous bath, by which the patient was fastened in
a hammock, placed in a tub, then covered with a canvas sheet that
allowed his or her head to remain exposed. The tub was then filled
with water of varying temperatures, with the treatment lasting
hours or even days. The second regimen—the wet sheet pack—
involved firmly wrapping patients in sheets dipped in water of vary-
ing temperatures (40–100°F, or 5–38°C). The treatments were
often justified on the basis that they relieved cerebral congestion
and removed bodily toxins.
The following excerpt is an autobiographical report by a woman
who underwent hydrotherapy at the Government Hospital for the
Insane in Washington, DC, around the turn of the twentieth cen-
tury. It is interesting not only because the patient—a trained nurse
by profession—discusses her attitude toward the treatment, but

245
246 — The New Focus on the Body
also because she provides a firsthand account of the experience of
manic depression (now known as bipolar disorder). Her physician
Eva Reid published this account, remarking that, at the time of writ-
ing this, the woman was in a “state of hypomania.” Upon later com-
ing to her senses, she was allowed to reread her statement, and
“while she confirmed the truth of all her statements, she affirmed
that she had forgotten many of her strange experiences at that time,
and the recalling of them to her was painful in the extreme.”

Early in January, 1908, I was seized with an unspeakable physical weari-

ness. There was a tired feeling in the muscles unlike anything I had ever
experienced. A peculiar sensation appeared to travel up my spine to my
brain. I had an indescribable nervous feeling. My nerves seemed like live
wires charged with electricity. My nights were sleepless. I lay with dry, star-
ing eyes gazing into space. I had a fear that some terrible calamity was about
to happen. I grew afraid to be left alone. The most trivial duty became a for-
midable task. Finally mental and physical exercise became impossible; the
tired muscles refused to respond, my “thinking apparatus” refused to work,
ambition was gone. My general feeling might be summed up in the familiar
saying “What’s the use.” I had tried so hard to make something of myself,
but the struggle seemed useless. Life seemed utterly futile.
One day it seemed to my disordered mind that one of the vertebrae in
the dorsal region was pressed into position. The blood seemed to be carried
to my brain in such quantities that the skull was too small to contain the
brain enclosed therein. The feeling of emptiness gave way to a sensation of
fullness and pressure. It seemed as though the condition of cerebral anemia
had given place to one of congestion. By beating my head against the floor
and walls I believed that I had loosened up the sutures and gave the brain a
chance to expand. It certainly gave me relief. On two occasions a slight epis-
taxis seemed to relieve the pressure and clear my thinking processes. This
confirmed my theory of cerebral congestion. I had a feeling that cranial
nerves on the left side were adhering to the skull as ivy clings to a stone
wall. Beating my head against the wall appeared to tear them loose from
their support and relieve the tension. The muscles which heretofore had
refused to respond to stimuli now refused to remain at rest. To keep phys-
ically quiet was an utter impossibility. The strain of trying to keep still was
 “Autopsychology of the Manic-Depressive” — 247
fast wearing me out. I would lie in bed and jump up and down on the
springs; I would make numerous excuses to go for a drink and to the toilet,
simply to be doing something. My thought processes which hitherto had
been retarded, and their expression difficult, now began to flow with light-
ning rapidity. Thoughts crowded into my mind too rapidly for expression.
Talking was the greatest relief imaginable. Formerly I was afraid to be left
alone, now the one thing for which I longed was solitude. This was denied
me. I was at this time a patient in a general hospital, of which I was formerly
assistant superintendent of nurses, and it was considered necessary to “spe-
cial” me night and day. Constant observation was maddening. There was
an ever-present fear that in my constant talking, which I was unable to con-
trol, I would reveal professional secrets that had been entrusted to my care.
In my official capacity as assistant superintendent I had been the receptacle
of many confidences by the doctors, superintendent, nurses, and patients.
These confidences—many of them too sacred to be bared for common
curiosity—weighed on me constantly, and I dreaded lest in my delirium I
would reveal them. Over-anxiety to retain mastery of my mind caused an
extreme tension of the nerves all over my body. The presence of a nurse,
always at my bedside, drove me frantic. Restraint was irritating and almost
fatal. The fact that I was being watched and observed rendered sleep impos-
sible. Drugs had no effect. I begged to be sent to the Government Hospital
for the Insane. My one desire was to get away from over-anxious and over-
curious friends and acquaintances. On March 1, 1909, I was removed at my
own request to the Government Hospital, to recover, to go permanently
insane, or to die. I confidently expected the last would be my fate.
Words fail to describe the feeling of relief I experienced when I was at
last placed in a strong room at my own request. To be alone, to be shut off
from the observation of the anxious and the curious, to be free to act and
talk in any way my distorted fancy dictated was relief unspeakable. Here I
was among strangers who cared nothing for the secrets I disclosed. They
did not even stop to listen to them. They did not appear to be surprised or
shocked at my wildest words or actions. I was not told a hundred times a
day that I must keep quiet. I talked, laughed, cried, sang, shouted, and
danced to my heart’s content. The giving up of all attempt at self-control
brought the needed rest and sleep.
The condition of my mind for many months is beyond all description.
My thoughts ran with lightning-like rapidity from one subject to another.
248 — The New Focus on the Body
I had an exaggerated feeling of self importance. All the problems of the uni-
verse came crowding into my mind, demanding instant discussion and
solution—mental telepathy, hypnotism, wireless telegraphy, Christian Sci-
ence, women’s rights, and all the problems of medical science, religion, and
politics. I even devised means of discovering the weight of the human soul,
and had an apparatus constructed in my room for the purpose of weighing
my own soul the minute it departed from my body. At one time I was
elected to Congress by my own district. I was teacher, preacher, reformer,
lawyer, judge, physician, actress, artist, poet, and writer, all within a won-
derfully short space of time. Probably my most important delusion was
that I was at the Government Hospital for the purpose of thorough inves-
tigation, supervision, and reformation. Each article of clothing and bedding
given me was tested by pulling on it with all my might. If it tore, I imme-
diately condemned it as being unfit for use, and tore it into shreds. I
decided it was manufactured by convict labor, and utterly unfit to be used
by an august person like myself. The crockery I tested by throwing it
against the walls and ceiling. If it broke it proved to me conclusively that it
was unfit for use in a government institution. I felt it my duty to train and
instruct the nurses. My efforts in this direction seemed unappreciated. The
valuable instruction so freely tendered was set at naught, spurned and
trampled underfoot. In fact, I do not think they even stopped to digest it.
Although my egotism was unbounded, yet I never for one moment was
happy. Always being accustomed to bear responsibility, the exalted role I
played served only to increase the burden of care. The propagation of all
reforms for the betterment of the human race devolved upon me. I
arranged programs and entertainments for Decoration Day, Fourth of July,
Labor Day, Thanksgiving, and Christmas. I staged “Tillie the Mennonite
Maid,” managed a circus, conducted revival meetings for the benefit of the
colored men who worked on the lawn. I made countless speeches, watch-
ing the facial expression of the other patients to see the effects of my ora-
tory. This was usually far from encouraging. I designed cartoons,
composed newspaper articles, diagnosed cases, prescribed treatment,
planned kindergarten games. I sang by the hour, with an idea of chest
expansion and voice culture. I tried cases in court, weighed the evidence
pro and con, and rendered my valuable (?) decisions. I “bossed” the car-
penters who repaired the porch where I sat. I gave advice to the painters. I
never failed to obey the biblical injunction to “entertain strangers.” For the
 “Autopsychology of the Manic-Depressive” — 249
benefit of the visitors who came in the ward, I performed athletic “stunts,”
improvising apparatus. This often necessitated the removal of the bolts
from the beds. The bowls in which the soup was served made excellent
missels [sic] with which to practice for a baseball pitcher. The pieces were
even more useful. They made more noise, and could be used to make deep
indentures in the walls of my room. The doors were of pine, and by
scratching them deeply with pieces of broken dishes I could smell the odor
of the pine tree, which was very agreeable. My inability to throw straight
was all that saved the electric light in my room. The hair from the inside
of my pillow and mattress was just what I needed to make a wig in which
to impersonate an old lady in my plays. The ticking from the pillow was
converted into a sunbonnet to represent the girl whose picture is on the
back of the music of “School Days.” The blankets torn into strips made
excellent bandages, and were just what I needed for teaching purposes. I
tore the sheets into strips and arranged designs for kindergarten games on
the floor. In all this I had a feeling of resourcefulness, and many times
called to mind the saying of the superintendent of our hospital: “If there’s
one think [sic] I admire it’s a woman of resources.” Thoughts chased one
another through my mind with lightning rapidity. I felt like a person driv-
ing a wild horse with a weak rein, who dares not use force, but lets him run
his course, following the line of least resistance. Mad impulses would rush
through my brain, carrying me first in one direction then in another. To
destroy myself or to escape often occurred to me, but my mind could not
hold one subject long enough to formulate any definite plan. My reasoning
was weak and fallacious, and I knew it.
My sleep was so fraught with dreams that I derived little benefit there-
from—dreams, delusions, and reality were so closely interwoven that even
now I cannot tell one person from another. Hallucinations of sight were
probably present. From the lower ventilator of my room came many ani-
mals nightly. These had been rescued from an untimely death by the anti-
vivisectionists. The most formidable of these was a young alligator which
gave me quite a shock when he first appeared. The sparrows and cats seen
from my window acted “dopey.” I concluded they had been fed arsenic as
an experiment. The nurses and physicians were recognized as persons I had
known, or of whom I had heard. One nurse was Ida Tarbell, in the hospi-
tal for the purpose of investigation; another was Ellen Terry, another Sis
Hopkins, another a lion tamer from the circus. One of the patients was
250 — The New Focus on the Body
Hetty Green, also investigating.* The nervous mechanism of the eye
seemed to be affected. A distinct myopia was present. On only a few occa-
sions did hallucinations of smell appear. Once I smelled burning rubber
very distinctly, and on two occasions my room was filled with the perfume
of flowers. One patient I imagined had been drinking embalming fluid, and
each time she came near me I was nauseated by the odor. My sense of taste
was impaired. Food and drink were obnoxious to me. I realized the impor-
tance of proper nourishment, however, and forced myself to eat and drink
everything that was brought to me. I had fleeting delusions that the food
was poisoned, but I still persisted in eating.
The sensation of physical pain which I endured is beyond my powers
of description. Every afternoon I was seized by the most violent paroxysm
of pain which racked every nerve in my body. The alimentary system
throughout felt as though it were one rotten mass. With more or less reg-
ularity a convulsion would attack the intestines at about the sigmoid flex-
ure, work its way up the descending colon, across the transverse, down the
ascending colon, up through the coils of the small intestines; lessening in
force it would attack the stomach, wriggle through the esophagus and dis-
appear. My head would be drawn back and I would rest on my head and
heels. By carefully massaging up and down on either side of the spinous
process of the vertebrae the tension would gradually be relieved. One night
the circulation in my lower extremities seemed to stop. My limbs were par-
alyzed. This was accompanied by an indescribable feeling at the base of the
spine, and a tingling of the nerve trunks. After much pinching, massaging,
and manipulation the circulation was again restored. From two until four in
the afternoon during the hottest months, it seemed impossible to derive
any oxygen from the air. Respiration was labored and painful. From time to
time I suffered all the symptoms and complications of every disease known
to medical science from exophthalmic goiter to scarlet fever. Carcinoma of
the lungs was my favorite malady.
Hydrotherapy worked wonders. What I enjoyed most was the shower
and spray. It was invigorating and refreshing, and seemed to give me a new

*Editor’s note: Ida Tarbell (1857–1944) was a writer famous for her exposé of John
D. Rockefeller and the Standard Oil Company. Ellen Terry (1847–1928) was an
acclaimed stage actress. Sis Hopkins was a beloved stage play that chronicled the
exploits of an awkward, rural girl. Hetty Green (1834–1916) was an eccentric
heiress, famous for her stinginess.
 “Autopsychology of the Manic-Depressive” — 251
lease of life. The packs I disliked at first. The restraint of the blankets
around me was maddening, it seemed like a dare, and on several occasions
I wriggled myself loose and escaped. However, after I became accustomed
to them they were soothing and I frequently slept while being treated in
this manner. The continuous bath was restful and quieting. My circulation
was poor, and I suffered from cold even in the warmest weather. The con-
tinuous bath appeared to restore the circulation, and the warmth in the tub
was grateful and soothing. The sheet thrown over me in the tub was irri-
tating and worried me constantly. I wanted to be free to splash around as I
pleased.
The two things I could not endure were restraint and observation. Had
my lot fallen in a hospital where restraint was used I tremble to think what
the outcome would have been. Sitting on the porch under the eye of a nurse
seemed an unnecessary curtailment of my liberties. Several times I escaped,
but was always followed and returned. To have someone watching me was
unendurable, inasmuch as I realized in a way how foolish my words and
actions were. One night one of the supervisors came in my room and stood
for a minute watching me eat my supper. This maddened me so that I
threw the tray and all its contents at her head.
The first symptom of recovery was a gradually increasing power to
direct my thoughts into desired channels. I discovered that what seemed to
be fact were in many cases delusions. Suddenly one day a feeling of self-con-
trol returned. The rapidity of thought seemed greatly lessened, and I was
once more able to concentrate my mind on one subject for more than a few
minutes at a time. Then came the feeling that I was well and must go home.
Previous to this I realized my abnormal mental condition, and had no
desire to see or be seen by my friends. Now I was seized with an eager long-
ing to see my relatives and friends. It was like coming back from the dead.
I overcame my restlessness by cleaning, scrubbing, mending, and writing.
My brain seemed unusually active and clear. I wrote for hours at a time;
essays, poems, aphorisms, etc., flowed from my pen with great rapidity. I
again began to take an interest in my personal appearance, and gradually
returned to my normal mental state.

From Eva Charlotte Reid, “Autopsychology of the Manic-Depressive,” Journal of

Nervous and Mental Diseases 37 (1910): 606–620.
252 — The New Focus on the Body

Herman Lundborg
(1868–1943)

“The Danger of Degeneracy”

(1922)

In the wake of the popularity of Charles Darwin’s (1809–1882) the-

ory of the evolution of species by natural selection, a number of
writers, policymakers, and researchers during the last third of the
nineteenth century became concerned that Western civilization,
instead of progressively evolving, was devolving or degenerating.
Among the signs they believed that pointed to this degeneration
were increasing crime rates and the growing number of those insti-
tutionalized as mentally ill and “feeble-minded.” Over the course of
the first decades of the twentieth century, local, national, and inter-
national organizations formed to press governments and individuals
to more aggressively combat degeneracy. These impulses crystal-
lized in the form of eugenics—a scientific and social movement
demanding that society could and should be deliberately improved
by encouraging those with the most desirable physical and mental
attributes to reproduce and discouraging all others.
One of the regions where eugenics enjoyed strong support was
Scandinavia. There, beginning in the 1930s and continuing after
World War II, states passed a series of laws instituting the some-
times voluntary, sometimes mandatory, sterilization of the mentally
ill and mentally disabled. Hundreds of thousands were sterilized
under these laws: eleven thousand in Denmark between 1929 and
1960, fifty-eight thousand in Finland between 1935 and 1970, and
forty thousand in Norway between 1934 and 1977. In Sweden,
where sixty-three thousand were sterilized in the years 1934–1975,
90 percent were women. The following outline of eugenic princi-
ples and policies is the work of Swedish psychiatrist and neurologist
Herman Lundborg. Lundborg was the head of the Institute for Race
Biology (founded in 1922) in Uppsala, Sweden, and an advocate for
strong eugenic legislation to protect what he termed a “Western
world in danger.”
 Lundborg, “The Danger of Degeneracy” — 253
Eugenic Theses and Guide-Lines

a.
1. A good national-material is the greatest riches a country can possess.
The material of the people depends in the highest degree upon the quality
of the hereditary mass. This is different in different nations.
2. Heredity and selection are the chief influences which govern life in this
world. Environment is certainly also of significance, although it cannot
develop new qualities but can only modify those already present, in the one
or the other direction.
3. Families and nations are governed by strict laws in the same way as the
private individual. One of the first tasks laid upon every civilized nation is
the careful investigation of these biological laws of nature, and afterwards
the regulation and arrangement of the conditions of society to suit these
laws. If we break them we must ourselves bear the consequences: we degen-
erate and go under. These laws, however, are not altogether and only stern
avengers. Rightly understood and obeyed they form a richly yielding source
of improvement and progress.
4. A glaring waste of the national-material is to be found at present
among many of the civilized nations and even with us. Material of great,
and to a large extent irreplaceable, value is being lost with alarming rapid-
ity. And it cannot be recovered in the same hasty manner as it is being
thrown away.
5. Many reasons co-operate in bringing this about. The principal seem to
be: (a) the sinking birthrate among the middle classes (among the peasant
population) who possess stronger race energy than the other strata of soci-
ety; (b) great industrial activity; (c) hasty race-mixture between nations,
who from a race-biological point of view, stand too far apart; (e) [sic] lux-
ury and the worship of mammon with the destruction of moral worth,
which accompanies it, etc.
6. The system of having none, one or two children practiced by the more
valuable strata of the people, while at the same time the lower and inferior
strata increase relatively quickly, must lead to the deterioration of the race
and the degeneration of the nation. The better off classes, especially the
women of these classes, without any valid reason, show an increasing dis-
position to withdraw from parenthood. By so doing they shirk their duty
and betray their own people. The decided individualism of our time, the
254 — The New Focus on the Body
great claims made on life, together with the decided over-estimation of the
power of environment and education, are important reasons leading in this
direction. The public opinion in a country and the authorities of the State
have also a heavy burden of guilt to bear in this respect.
7. Industrial and agricultural occupations demand, at least at times,
increased and new energy. Partly for this reason and partly to defend the
country from outward foes, owing to a low birth-rate in a country, foreign-
ers belonging to an inferior race must be called in. In ancient Rome during
its decline and fall the circumstances were exactly the same. Race-mixtures
arise in such cases causing a mixed nation of inferior quality. This must
sooner or later overthrow the ancient civilisation of the country. Chaos and
anarchy become the ruling powers. Other nations force their way in and
gradually the older civilisation is obliterated.
8. It certainly lies within the boundaries of possibility to take up seriously the
struggle against these threatening and destructive factors. Such a course implies,
however, that all good citizens within a country, irrespective of their social,
political, and religious views, should unite their forces and work together
for a common goal, rich in promise, the defence of their own national
against internal revolutionary and race-degenerative tendencies.
For this is demanded: good will and combination, financial self-sacrifice,
greater morality and real love of humanity.

3.
1. An energetic work of enlightenment on the subject ought to be carried
on. Beginning with Universities, High Schools and Training Colleges as the
starting point, public opinion ought to be worked upon by means of both
lectures and writing. Medical men and teachers out to be specifically edu-
cated in the science of heredity and race-culture. The feeling of responsi-
bility towards the coming generations must be aroused. No full-grown
person ought to be ignorant concerning the great significance of parent-
hood, and all must learn to understand the meaning of well-born from a bio-
logical point of view.
2. Race-biological institutes for investigation with the object of studying
hereditary questions and eugenic problems on all sides ought to be estab-
lished in every civilized country as soon as possible. This had already been
done in Sweden. The institute ought to be guided by genealogical, medical-
biological, and social-economical principles. The instinct of self-preservation
 Lundborg, “The Danger of Degeneracy” — 255
ought now, after the world war, to drive the civilized nations towards start-
ing this work without delay.
3. Severe diseases among the people such as alcoholism, sex diseases and
tuberculosis must be fought against strenuously.
4. A simple and industrious manner of life must be inculcated among all
classes of the population, at the same time that due exercise of the body and
sound sport are striven after. Luxury and an unchecked desire for pleasure
do not bring honour to any nation; they counteract the development of race
in a favourable direction.
5. Social “swamps” ought to be drained by means of wise reforms and
far-sighted law-making. The necessary supervision and care is not yet
given to individuals who are really degenerate—and such are to be found
in large numbers, both in our own land and in other civilized countries—
but they are allowed to influence the race in an obstructive and dangerous
manner. We ought to pay the greatest attention to political questions
regarding the population and allow the eugenic point of view always to
have full consideration.
6. The State and private persons ought to unite in building pattern
homes out in the country as a counter-balance to the industrialism which so
often proves an enemy to the race and to the health of the people. A sound
agricultural population with a high birth-rate is a necessary condition of life
for a nation that does not wish to degenerate. An independent peasant class
makes the groundwork, “backbone” of a nation. This class ought therefore
to be helped and cherished as much as possible. The de-population of the
countryside must be sternly opposed, but not by the introduction of indus-
trialism there also. Home colonization ought to be encouraged.
7. Emigration, which has caused considerable drain on the life-blood of
the nation, ought, if possible, to be regulated and kept within proper
bounds.
8. We must also pay attention to immigration so that inferior individu-
als belonging to foreign races cannot enter the country and settle without
any hindrance. A mixture between nations who, from a race-biological
point of view, stand high and others containing lower race-elements, such
as gipsies [sic], Galicians, certain Russian tribes, etc., is certainly to be con-
demned.
9. The science of eugenics, which is a real patriotic movement according
to the true meaning of the words, has for its object the strengthening and
256 — The New Focus on the Body
improvement of our people both bodily and mentally, and ought therefore
to be able to reckon on having the support of all classes of society.
10. Widely spread national societies ought to be formed in all the civi-
lized countries with the object of working for race-culture, the health of the
people and the improvement of morality.
Rich citizens within the country could hasten the spread of eugenic
ideas in a high degree by means of financial and moral support. These ideas
ought not to remain in the long run only futile desires.

From Herman Lundborg, “The Danger of Degeneracy,” Eugenics Review 14 (1922):

41–43.

The Decision in Buck v. Bell

(1927)

In the United States, Indiana passed the first eugenic sterilization

law in 1907. Other states soon followed suit, including Virginia in
1924 (The Racial Integrity Act). Carrie Buck (1906–1983) and her
mother, Emma, were both committed involuntarily to the Virginia
Colony for Epileptics and Feeble Minded in Lynchburg, Virginia.
The superintendent of the facility, Albert Priddy, judged both
women, as well as Carrie’s seven-month-old daughter, Vivian, to be
feeble-minded, later testifying in court that the women “belong to
the shiftless, ignorant, and worthless class of anti-social whites of
the South.” Priddy chose Carrie Buck to be the first person to be
sterilized under the new law.
The case went to court, where expert testimony was solicited
from a teacher, a field worker, and the eugenicist Harry Laughlin.
Their testimony painted a picture of Emma and Carrie Buck as sex-
ually promiscuous and morally degenerate. The case was eventually
appealed to the U.S. Supreme Court—in the meantime, Priddy had
died and his position was taken by J. H. Bell—which upheld the law
with only one dissenting vote. Carrie Buck was sterilized on 19
 Buck v. Bell — 257
October 1927. Virginia’s sterilization law was repealed in 1974. In
2001 the Virginia State Assembly expressed its “profound regrets”
for the state’s involvement in eugenics, and in May 2002, Governor
Mark Warner formally apologized on behalf of Virginia, calling the
eugenics movement “a shameful effort in which state government
never should have been involved.” All told, some thirty U.S. states
had similar laws, under which around sixty-five thousand individu-
als were sterilized.

U.S. Supreme Court

Buck v. Bell,
Superintendent of State Colony for Epileptics and Feeble Minded
Argued April 22, 1927. Decided May 2, 1927.
Mr. Justice Holmes delivered the opinion of the Court.

This is a writ of error to review a judgment of the Supreme Court of

Appeals of the State of Virginia, affirming a judgment of the Circuit Court
of Amherst County, by which the defendant in error, the superintendent of
the State Colony for Epileptics and Feeble Minded, was ordered to perform
the operation of salpingectomy upon Carrie Buck, the plaintiff in error, for
the purpose of making her sterile. 143 Va. 310, 130 S. E. 516. The case
comes here upon the contention that the statute authorizing the judgment
is void under the Fourteenth Amendment as denying to the plaintiff in
error due process of law and the equal protection of the laws.
Carrie Buck is a feeble-minded white woman who was committed to
the State Colony above mentioned in due form. She is the daughter of a fee-
ble-minded mother in the same institution, and the mother of an illegiti-
mate feeble-minded child. She was eighteen years old at the time of the trial
of her case in the Circuit Court in the latter part of 1924. An Act of Vir-
ginia approved March 20, 1924 (Laws 1924, c. 394) recites that the health
of the patient and the welfare of society may be promoted in certain cases
by the sterilization of mental defectives, under careful safeguard, etc.; that
the sterilization may be effected in males by vasectomy and in females by
salpingectomy, without serious pain or substantial danger to life; that the
Commonwealth is supporting in various institutions many defective per-
sons who if now discharged would become [274 U.S. 200, 206] a menace,
but if incapable of procreating might be discharged with safety and become
258 — The New Focus on the Body
self-supporting with benefit to themselves and to society; and that experi-
ence has shown that heredity plays an important part in the transmission
of insanity, imbecility, etc. The statute then enacts that whenever the
superintendent of certain institutions including the abovenamed State
Colony shall be of opinion that it is for the best interest of the patients and
of society that an inmate under his care should be sexually sterilized, he
may have the operation performed upon any patient afflicted with heredi-
tary forms of insanity, imbecility, etc., on complying with the very careful
provisions by which the act protects the patients from possible abuse.
The superintendent first presents a petition to the special board of
directors of his hospital or colony, stating the facts and the grounds for his
opinion, verified by affidavit. Notice of the petition and of the time and
place of the hearing in the institution is to be served upon the inmate, and
also upon his guardian, and if there is no guardian the superintendent is to
apply to the Circuit Court of the County to appoint one. If the inmate is a
minor notice also is to be given to his parents, if any, with a copy of the peti-
tion. The board is to see to it that the inmate may attend the hearings if
desired by him or his guardian. The evidence is all to be reduced to writ-
ing, and after the board has made its order for or against the operation, the
superintendent, or the inmate, or his guardian, may appeal to the Circuit
Court of the County. The Circuit Court may consider the record of the
board and the evidence before it and such other admissible evidence as may
be offered, and may affirm, revise, or reverse the order of the board and
enter such order as it deems just. Finally any party may apply to the
Supreme Court of Appeals, which, if it grants the appeal, is to hear the case
upon the record of the trial [274 U.S. 200, 207] in the Circuit Court and
may enter such order as it thinks the Circuit Court should have entered.
There can be no doubt that so far as procedure is concerned the rights of
the patient are most carefully considered, and as every step in this case was
taken in scrupulous compliance with the statute and after months of obser-
vation, there is no doubt that in that respect the plaintiff in error has had
due process at law.
The attack is not upon the procedure but upon the substantive law. It
seems to be contended that in no circumstances could such an order be jus-
tified. It certainly is contended that the order cannot be justified upon the
existing grounds. The judgment finds the facts that have been recited and
that Carrie Buck “is the probable potential parent of socially inadequate off-
 Buck v. Bell — 259
spring, likewise afflicted, that she may be sexually sterilized without detri-
ment to her general health and that her welfare and that of society will be
promoted by her sterilization,” and thereupon makes the order. In view of
the general declarations of the Legislature and the specific findings of the
Court obviously we cannot say as matter of law that the grounds do not
exist, and if they exist they justify the result. We have seen more than once
that the public welfare may call upon the best citizens for their lives. It
would be strange if it could not call upon those who already sap the
strength of the State for these lesser sacrifices, often not felt to be such by
those concerned, in order to prevent our being swamped with incompe-
tence. It is better for all the world, if instead of waiting to execute degener-
ate offspring for crime, or to let them starve for their imbecility, society can
prevent those who are manifestly unfit from continuing their kind. The
principle that sustains compulsory vaccination is broad enough to cover
cutting the Fallopian tubes. Jacobson v. Massachusetts, 197 U.S. 11 , 25 S.
Ct. 358, 3 Ann. Cas. 765. Three generations of imbeciles are enough. [274
U.S. 200, 208] But, it is said, however it might be if this reasoning were
applied generally, it fails when it is confined to the small number who are
in the institutions named and is not applied to the multitudes outside. It is
the usual last resort of constitutional arguments to point out shortcomings
of this sort. But the answer is that the law does all that is needed when it
does all that it can, indicates a policy, applies it to all within the lines, and
seeks to bring within the lines all similarly situated so far and so fast as its
means allow. Of course so far as the operations enable those who otherwise
must be kept confined to be returned to the world, and thus open the asy-
lum to others, the equality aimed at will be more nearly reached.
Judgment affirmed.
Mr. Justice Butler dissents.

From U.S. Supreme Court, Buck v. Bell, 274 U.S. 200 (1927), FindLaw, http://
laws.findlaw.com/us/274/200.html.
260 — The New Focus on the Body

Julius Wagner-Jauregg
(1857–1940)

“The Treatment of Dementia

Paralytica by Malaria Inoculation”
(1927)

The Viennese psychiatrist Julius Wagner-Jauregg did his studies at

an experimental pathology institute, where he first became
acquainted with using laboratory animals in experiments. He then
became a professional psychiatrist, in 1883, with virtually no expe-
rience in treating patients. His interests soon led him to investigate
the possible therapeutic benefits of induced fevers for psychiatric
disorders, and in 1917, Wagner-Jauregg began inoculating patients
with malaria-infected blood in order to produce these fevers.
Malaria inoculation grew to be a widely accepted treatment, par-
ticularly for general paresis (progressive paralysis), during the years
1920–1950. Physicians generally infected patients by injection or
mosquito bites or by rubbing infected blood on open cuts. After
about a week, the patient experienced chills and nausea, followed by
a series of alternating spells of fever and chills. Fevers reached as
high as 106°F (41°C). Quinine sulfate was then administered to
treat the malaria. In 1927, Wagner-Jauregg was awarded the Nobel
Prize for Physiology or Medicine. The following excerpt comes
from the lecture he gave that year.

Nobel Lecture, December 13, 1927

Two paths could lead to a cure for progressive paralysis: the rational and the
empirical. The rational path appeared to be practical, as since Esmarch and
Jessen, in 1858, attention had been drawn to a connection between pro-
gressive paralysis and syphilis. If incontestable proof that progressive paral-
ysis was a syphilitic brain disease was first given much later (I mention in
this connection the names Wassermann and Noguchi), therapeutic
 Wagner-Jauregg, “Malaria Inoculation” — 261
attempts to apply anti-syphilitic treatments were nevertheless instituted
much earlier.
Established psychiatry, it is true, soon turned away from the specific
therapy. In all the textbooks it was stated that the mercury cure was of no
use against paralysis and was usually harmful. . . .
The discovery of arsphenamine (Salvarsan) by Ehrlich brought new
hope. The disappointment which soon followed was due to quite insuffi-
cient dosages. As one reads the reports of writers who have given arsphen-
amine in large doses and in rapidly repeated courses of treatment, and when
one hears of the remissions obtained, in number and in duration far supe-
rior to the number of remissions observable in untreated paralysis, it can-
not confidently be maintained that arsphenamine is ineffective against
progressive paralysis. Yet it seems indeed, disregarding rare exceptions, that
sooner or later a point is reached where arsphenamine treatment is unable
to halt the fatal progression. The augmentation of the treatment by the
employment of bismuth preparations could not change this.
There are, however, still always writers who expect the cure of para-
lytics from specific treatment alone.
But the question is not one of prestige between specific and non-spe-
cific treatment, but of what is the most far-reaching therapeutic effect on
the disease obtainable.
And thus we have arrived at the empirical method.
Progressive paralysis has always been regarded as an incurable disease
leading within a few years to insanity and death.
Nevertheless there were records of cured cases of progressive paraly-
sis; cases in which there was such a complete retrogression of all the
symptoms of the disease that it was possible for the person concerned to
go about his life and business independently for many years. And even
though such cases were extraordinarily rare, there were still relatively fre-
quent remissions of a considerable duration in which the symptoms of the
disease already developed retrogressed to a greater or less extent. Thus, in
principle at least, progressive paralysis was necessarily a curable disease.
And Francis Bacon, Lord Verulam, had already pronounced that it must
be of the greatest interest for the physician to study healed cases of incur-
able diseases.
Now, the observation has been made that, in the rare cases of cure and
in the frequent remissions of progressive paralysis, a febrile infectious
262 — The New Focus on the Body
disease or protracted suppuration had often preceded the improvement in
the state of the disease. In that lay a pointer. These cures following febrile
infectious diseases, of which I had experienced striking instances myself, led
me to propose as early as 1887 that this natural experiment should be imi-
tated by a deliberate introduction of infectious diseases, and I suggested at
that time malaria and erysipelas as suitable diseases. I singled out as a par-
ticular advantage of malaria that there is the possibility of interrupting the
disease at will by the use of quinine, but I did not then anticipate to what
degree these expectations from induced malaria would be fulfilled.
At that time I did not proceed to the direct application of these pro-
posals, apart from an unfortunate experiment with erysipelas, and I also
hardly had the authority then to carry on with them.
On the other hand I attempted to imitate the action of a febrile infec-
tious disease by the use since 1890 of tuberculin which Koch had just
introduced. At first this was used not only in progressive paralysis, but also
in other mental disturbances, not infrequently with beneficial conse-
quences. (This was to some extent a forerunner of the use of protein ther-
apy, which later attained a great advance.) As there were among these,
some cases of progressive paralysis, my interest soon concentrated on this
disease because a favourable result cannot be so easily regarded as fortu-
itous as in other psychoses.
It was ascertained by means of a preliminary experiment of a large num-
ber of paralytics that those treated with tuberculin (with a maximum dose
at that time of 0.1) showed more and longer-lasting remissions and a longer
duration of life than an equal number of untreated paralytics. Afterwards,
this treatment was carried out systematically and with an increasing dose
of tuberculin (up to 1.0), and simultaneously a vigorous iodine-and-mer-
cury treatment, later accompanied by arsphenamine injections, was also
introduced.
In 1909, at the International Medical Congress in Budapest I gave some
information on these methods of treatment, which were thus the first com-
bined treatment—i.e. specific and non-specific—of a syphilitic disease.
Qualitatively the remissions which were obtained by means of the mer-
cury- tuberculin treatment did not differ from those to be attained through
induced malaria. The complete disappearance of the mental disturbances
and the resumption of business activity, even in professions which make
greater intellectual demands—such as civil servant, officer, barrister, solic-
 Wagner-Jauregg, “Malaria Inoculation” — 263
itor, teacher, industrialist, actor, etc.—and the duration of the remissions
was in individual cases quite remarkable; amounting to up to fifteen years.
But the number of relapses was great, the lasting remissions were in
the minority. I attempted to increase the effectiveness of the non-specific
treatment by the utilization of various vaccines—staphylo-streptococcal
vaccine, typhus vaccine—without altering the frequency of discouraging
relapses in the slightest.
In the course of this experimentation with treatments I was able to
observe repeatedly that particularly complete and long-lasting remissions
presented themselves precisely in those cases in which an unintentional
infectious disease, such as pneumonia or an abscess, appeared during the
course of the treatment.
In 1917, therefore, I commenced to put into practice my proposal made
in the year 1887, and I injected nine cases of progressive paralysis with tert-
ian malaria. The result was gratifying beyond expectation: six of these nine
cases showed an extensive remission, and in three of these cases the remis-
sion proved enduring, so that I was able to present these cases of cured
patients who have without interruption taken up again their former occu-
pations, to this year’s annual meeting of the German Psychiatric Society as
having been able to follow them for ten years. After the result of this first
experiment was pursued for two years, I went on, in the autumn of 1919,
to continue this experimental treatment on a large scale, and I made a
report on it in 1920 to the annual meeting of the German Psychiatric Soci-
ety in Hamburg.
Whereas the earlier non-specific methods of treatment of progressive
paralysis had met with little approval, it was otherwise with the malaria
treatment. After Weygandt and Nonne, stimulated by Mühlens in Ham-
burg, had first tested the method of treatment on a large number of
patients, it found quick acceptance in many psychiatric clinics and insane
asylums, and is currently used, as far as I am informed, in all the countries
of Europe, in North and South America, in South Africa, in the Dutch East
Indies, and in Japan.
The overwhelming majority of writers agree that with this method
remissions can be obtained which are on a scale far exceeding those
attained by any other method.
Nevertheless, the malaria treatment should not simply replace specific
treatment but should be used in conjunction with it. Some writers believed
264 — The New Focus on the Body
at first that they could dispense with the specific treatment, in that they
obtained brilliant remissions by malaria alone. But the question is how to
obtain the maximum therapeutic effect from the treatment. So, I undertook
comparative investigations in which paralytics admitted to the clinic were
treated alternately, the one with malaria only, the other with malaria fol-
lowed by neoarsphenamine. The superiority of the combined specific-non-
specific treatment was clearly shown.
The cases which had been subsequently treated with neoarsphenamine
had 48.5% full remissions, those with no subsequent treatment only 25%.
On the other hand, the number of deaths in the latter group was higher—
18.7% against 12%—and likewise the number of rapidly deteriorating
cases was 22% against 6.7%.
The malaria treatment is thus to be associated with a specific treat-
ment. Insofar as neoarsphenamine is concerned, the drug should be given
first after the fever has subsided, as otherwise the malaria is cut short. In
my clinic now 5.00 grams of neoarsphenamine are given over six weeks
after each malaria treatment.
Malaria treatment is the more effective the earlier in the course of the
paralysis it is carried out. Therefore it is impossible to get a correct picture
of its potential effectiveness by simply calculating that out of such and such
a number of paralytics treated with malaria so many per cent obtained com-
plete remission. It depends very much on how many among the material in
question were in the initial stages of paralysis and how many were in the
advanced stages.
We have therefore for some time singled out from the first, those cases
of paralysis on their very first arrival at my clinic which from the degree
and duration of their illness promised a favourable outcome and followed
their progress separately. It was shown, that of these cases 84.8% obtained
a full remission and 12.1% a partial remission, and that out of the total
number of this series only one in thirty-eight had to be committed to the
asylum.
Hence it was shown that progressive paralysis is, in principle, curable
and that the practical success of the malaria treatment will be the greater
the earlier the diagnosis of the illness is established—the more, that is, that
the early stages of paralysis are recognized by physicians. It has become
apparent that it is unwise to employ other methods of treatment against
paralysis before the malaria treatment, as this means time wasted.
 Wagner-Jauregg, “Malaria Inoculation” — 265
As the malaria treatment is the more effective the earlier it is employed,
it would thus be best if it were carried out immediately on those luetics who
are threatened with progressive paralysis. Which luetics are these? We
know that they are those luetics in whom the cerebrospinal fluid in the
advanced period of latency gives a positive reaction.
It is due to the late Kyrle of Vienna that the malaria treatment was
extended to these luetics in that in these cases, which are not yet immedi-
ately threatened, he prescribed a course of arsphenamine to precede the
malaria, and a second course to follow it. The results in respect of the read-
justment of the cerebrospinal fluid, which in such cases with other meth-
ods of treatment is on the contrary frequently very refractory, were so
gratifying that already a large number of syphilologists have become
acquainted with these methods. And it is to be hoped that once these meth-
ods become public property, psychiatrists will have very much fewer para-
lytics to treat.
That the malaria treatment attained so great a dissemination is due to
some favourable results, only apparent during its application, which could
therefore not been expected from the beginning.
It would have been difficult in many places to continue the malaria
treatment if it had not been possible to maintain for an unlimited period a
malaria strain by continual passage through human beings—that is in the
asexual cycle. This was at first doubted, or at least the feat was stated, that
such a strain would, in the course of its passage, change its properties, i.e.
might become either no longer infectious or too virulent. These fears have
proved groundless. In my clinic there is a malaria strain in use that since
September 1919 has made about two hundred passages through human
beings, without its infectiousness, its virulence, and its therapeutic proper-
ties having been altered. Similar experiences have been had in many places.
The uninterrupted breeding of such a strain is, however, only possible
where there is access to a sufficiently large number of paralytics needing
treatment and possibly also of luetics in the advanced latency.
In places with little patient material, however, such a strain of induced
malaria will always die out again, and it would involve great and often insur-
mountable difficulties to always procure a new case of natural malaria again
to start a treatment, for the malaria virus will not breed in cultures.
Fortunately, however, the malaria parasites in human blood remain
infectious for some time outside the human body, and this capacity can, by
266 — The New Focus on the Body
special methods of preservation be maintained for up to three days and in
rare exceptions even longer, so that it is possible to send the virus over con-
siderable distances by various means of transport.
It is therefore possible to supply with malaria virus an area of a very
large radius from a centre, especially if use is made of the most modern form
of transport, air mail. In this way we once successfully supplied malaria
blood to Constantinople from Vienna.
It was finally a fortunate circumstance, which was not expected from
the first, that tertian malaria brought on by injection proved to be so extra-
ordinarily sensitive to quinine that a few grams of quinine suffice to cure
the malaria completely and permanently, so that there is no fear of a relapse.
It was through this that the great expansion which induced malaria has
gained was first made possible.
When tertian malaria is acquired naturally the attacks of fever may also
be cut short very effectively with quinine, but the patients remain carriers
of the plasmodium and frequently relapse sooner or later. How would it
have been possible to release so many paralytics and advanced syphilitics
from the hospitals when outside they first of all ran the continual risk of a
relapse and secondly, particularly where there were anopheles, were a dan-
ger to their environment?
The patient inoculated with malaria who has been adequately treated
with quinine neither endangers himself further (in the sense of a malaria
relapse), nor can he endanger his environment. However, he can from the
moment of infection up to the elimination of the malaria present a danger
to his environment, as malaria can be transferred from him to other persons
through the sting of the anopheles, and that is then not induced malaria,
but natural malaria, with its resistance to quinine.
This danger, which was assumed with the presence of anopheles in
places of treatment, can be excluded with a fair degree of safety, if the
patients are kept under mosquito-proof netting during the whole duration
of the treatment. This has been done in several countries, such as England
and Sweden.
The question is whether it is not possible to meet this danger in yet
another way. An experiment was made in my clinic in 1924 with a large
number of patients and mosquitoes to see if induced malaria could be trans-
ferred to other patients through anopheles; the experiment was without
results. Such transfers have, however, been obtained by other writers[;]
 Wagner-Jauregg, “Malaria Inoculation” — 267
notably Shute and James, and also Warrington Yorke, in England, have car-
ried out numerous successful transfers of induced malaria by means of
anopheles. The Vienna strain has, however, been proved at that time to be
free of gametes by an experiment of the Italian malariologist D. Vivaldi. The
strains which were transferable through anopheles have all proved to be
gamete producers; and the English writers mentioned in particular state
that the transference by anopheles is the easier, the richer in gametes the
donor’s blood is.
Plehn and Schulze of Berlin, and Vonkenel of Munich, also reported on
such gamete-free strains.
I have therefore in the preceding year made the demand that everyone
who practices malaria therapy, should procure a gamete-free strain and thus
eliminate the danger of a transfer by means of anopheles.
More recent investigations carried out in my clinic this year have, how-
ever, shown that this demand cannot be realized, as gamete-free malaria
strains cannot be obtained by transferring preserved blood unaltered from
one place to another. That is to say that it has been shown that from the
moment malaria blood leaves the human body, the malaria parasites deviate
from the normal course of development; they leave the red blood corpus-
cles and assume gametic forms.
We thus have in the preserved blood, not a gamete-free strain, but pre-
dominantly gamete-containing injection blood.
Thus the propagation of a gamete-free strain would not be possible
with preserved blood but only by direct transfer from one patient to
another. It would not be possible to effect this by transferring the blood but
only by transferring the patients.
Induced malaria is, however, of itself a dangerous disease. The attacks
of fever usually reach 40°C by the third attack. The temperature often
remains above 40°C for many hours in the later attacks. It frequently
reaches 41°C. The highest temperature that I have observed was 42°C. In
addition, the attacks frequently assume the quotidian type or take that
course right from the beginning. It appears, incidentally, that paralysis plays
a role in the appearance of the quotidian type, as in luetics of advanced
latency the malaria usually remains tertian. Perhaps in this respect, how-
ever, different strains of malaria behave differently, since Bravetta in Novara
has at his disposal a strain of which he reports that it causes without excep-
tion attacks of the tertian type.
268 — The New Focus on the Body
The high temperatures on the one hand and the brief pauses in the
quotidian type on the other, make on the usually already weakened organ-
ism of the paralytic, especially on his heart, often too great demands; and
thus we and others also have seen not by any means infrequent cases of
death during the fever period or immediately afterwards.
However, by various measures, this danger has been decreased to such
an extent that fatal cases are now almost never seen. We use several meth-
ods to this end. Something can frequently be effected by the mode of inoc-
ulation. That is to say that, if one inoculates intracutaneously with a small
quantity of blood, about 0.1 cm3, the fever usually develops into the tertian
type, especially when the blood groups of the donor and recipient corre-
spond, and the avoidance of the quotidian type is already an alleviation.
In other cases we mitigate the fever with small doses of quinine
(0.2–0.3) which must not, however, be given two days in succession, oth-
erwise the fever ceases entirely. After a single administration of such a dose,
the fever disappears for some days, during which the patient recovers; and
when the fever sets in again it runs a milder course, as a rule. Alternatively
one gives 0.1 quinine every two or three days from immediately after the
injection, and in this way obtains a general alleviation of the course of the
fever.
Finally, in cases which on account of their physical constitution or on
account of their age—somewhere between 55 and 70—appear particularly
endangered, a division of the course into two parts has been proved partic-
ularly successful. In such patients the fever will be interrupted by quinine
after two to at the most four attacks. This is followed by a six weeks’ pause
taken up with injections of neoarsphenamine, after which the patient will
be infected a second time. He has meanwhile recovered, and now endures
the continuation of the cure very well.
In this connection the question also arises, how many attacks of fever
are necessary for a successful malaria cure? This can only be decided by
experience, as we have no biological evidence as to when the optimum
activity occurs. In my clinic the fever is, as a rule, terminated after eight
attacks. English writers, by comparing therapeutic results after a shorter or
longer duration of the fever period have likewise come to the conclusion
that the optimum therapeutic effect lies at around eight attacks.
Some writers have let their patients have very much longer fevers.
However, I believe that it is much better to give to a patient in whom a
 Wagner-Jauregg, “Malaria Inoculation” — 269
course of some eight attacks of fever has had an unsatisfactory result, a sec-
ond course soon afterwards, than to endanger the reconstruction which
should follow each malaria injection by weakening the patient too severely
by continuing the course too long.
This reconstruction as an aftereffect of induced malaria, and the long
duration of its aftereffect in general, is something that must be taken into
account by every explanation of the mode of action of induced malaria.
The improvement in the physical and mental health of the patients is
not as a rule demonstrable immediately after the last attack of fever and
never to the full extent. On the contrary, it often happens that a paralytic
who on completion of the treatment has been committed to the asylum as
uncured, presents himself again after six or twelve months and states that
he has taken up his occupation again.
The most convincing, because numerically demonstrable, expression of
this delayed action of induced malaria is in the reactions of the serum and
of the cerebrospinal fluid. The immediate effect of the malaria treatment on
these reactions is negligible, and the changes do not run parallel with the
clinical symptoms. It does change however, if these reactions are repeatedly
investigated at intervals.
Kyrle has already noticed that in the malaria treatment of advanced
syphilitics distinguished by a positive cerebrospinal fluid, the immediate
effect of the treatment was relatively small. However, after the space of a
year the cerebrospinal fluid was negative, although since the malaria, no
further treatment had taken place, and in spite of the fact that before the
malaria treatment the most vigorous specific therapy had been applied with-
out any result.
The same thing happens with paralytics, only at an even slower tempo.
In them the negativity of the cerebrospinal fluid reactions often first appears
two, three, and even four years after the malaria treatment and still without
any specific or non-specific treatment being introduced after the latter.
My assistant D. Dattner reported three years ago on the results of treat-
ment from a particular aspect on a series of 129 paralytics treated with
malaria in the period between the beginning of 1922 and the beginning of
1924; 66 of them underwent cerebrospinal fluid examinations at more fre-
quent intervals up to the present day. They were thus cases in whom the
malaria treatment lay about three to five years behind. Of these cases, re-
peated examinations of the cerebrospinal fluid in 1927 showed completely
270 — The New Focus on the Body
negative findings in 36, and nearly negative findings in 23. This favourable
result, however, had first appeared in many of them two or more years after
the cessation of the malaria treatment and without any further treatment
having been administered in the meantime.
It has been shown by these investigations that the serum reaction is
more refractory than the cerebrospinal fluid reaction.
The regularly repeated examination of the serum and cerebrospinal
fluid also provides good evidence to establish a prognosis for the remissions
achieved. Relapses, that is, do occur, but they form by far the minority
beside cases which have attained a full remission. However, the cases in
which this progressive improvement in the cerebrospinal fluid appears, do
not relapse; but the contrary does not hold good. Curiously enough, this
progressive improvement of the cerebrospinal fluid appears also in a num-
ber of the cases which do not improve clinically. It is thus of prognostic
value only in conjunction with the clinical findings.
How is the action of induced malaria on the paralytic process to be
explained? It is certain that it is not the high temperature alone that is effec-
tive. The spirochaetes, it is true, disappear from the brain during the fever.
When, however, the fever has passed, they are immediately to be found
again in the brain, at least in cases where the course is not successful, as
Forster has shown. Where are they in the meantime? Does malaria act
against syphilis in general or predominantly against progressive paralysis?
We know that syphilitic processes in the secondary period are also influ-
enced by malaria, yet this action appears to be less permanent than the
action on progressive paralysis. Vascular syphilis appears to be less
favourably affected than progressive paralysis. Further, it has been experi-
enced that soon after the malaria treatment gummata appear, even in cases
in which the paralytic process has been favourably affected.
It appears then, that malaria besides a non-specific action against the
syphilitic infection, also exerts a specific elective action on the cerebral
process of progressive paralysis, including advanced infection of the cerebro-
spinal fluid.
It is also very likely that malaria creates favourable conditions for all
reparatory processes because of its cyclic course, and because ultimately a
rapid transition takes place from a serious state of illness to a full recovery.
The superiority of induced malaria over the different types of stimulation
therapy, e.g. by the injection of vaccines and proteins, has been shown by
 Simon, Active Therapy in the Lunatic Facility — 271
Schilling and his colleagues on the cytological blood-picture, and by Donath
and Heilig on the chemical blood-picture. It is certain that induced malaria
therapy will yet pose many worthwhile problems for research to explain.

From Julius Wagner-Jauregg, “The Treatment of Dementia Paralytica by Malaria

Inoculation” Nobel Lecture, 13 December 1927, http://nobelprize.org/nobel_
prizes/medicine/laureates/1927/wagner-jauregg-lecture.html. With permission of
The Nobel Foundation.

Hermann Simon
(1867–1947)

Active Therapy in the Lunatic Facility

(1929)

Hermann Simon was a German psychiatric reformer, who made his

reputation during the first three decades of the twentieth century
developing what he called “active therapy.” He happened upon the
idea in 1905, when, because of a staff shortage, he set patients to
work on the asylum grounds at Warstein. To his surprise, he found
that patients were subsequently calmer and more orderly. Assuming
the directorship of the psychiatric facility at Gütersloh in 1919,
Simon implemented his form of occupational therapy throughout
the asylum there, and soon, 90 percent of its eight hundred resi-
dents were working. Under his charge, Gütersloh became a model
institution, visited by more than seven hundred guests between
1925 and 1933 and inspiring replicas throughout Europe. Simon
held strong conservative and nationalist beliefs and was admittedly
influenced by social Darwinism and eugenics.

From his experience in his own treatment halls, every attending physician is
familiar with the tendency of many of the ill to constantly pull their blankets
over their heads, day and night lying there rigid and motionless, rejecting
272 — The New Focus on the Body
any attempt to approach them. The simplest physiological consideration
leads us to the realization that the continued inhalation of the stuffy air
under the blanket must be having a detrimental effect on the gaseous
exchange and metabolism. A sufficient, normal metabolism must be the
most elementary basis for any kind of therapy for all illnesses, including
psychoses associated with brain disorders.
Another, perhaps most important, failing of this much touted bed rest
treatment in our system I see lying in the very fact that the one-sided ther-
apeutic esteem that is still to this day bestowed upon it prevents us from
taking timely action against the effects of the illness. This is especially the
case for many newly afflicted patients. To be sure, bed rest . . . is extraordi-
narily easy for doctors and staff, just like some other schemes in therapy. If
every newly arriving patient is placed in bed for weeks or months without
any attention to the type and course of their illness, if the bed has become
the sovereign cure for all sorts of problems that arise in the course of a psy-
chosis (agitation, anti-social tendencies, refusal to eat, etc), then the thera-
peutic thinking of the physician as well as that of the staff becomes very
simplified. At that very moment where the bed rest treatment appears to
demonstrate marked success—when, for instance, a formerly agitated and
disruptive patient is quieted under its influence—the danger of perpetual
bed rest exists for the patient, since supposedly “it’s better to be in bed than
outside” and (if the effort is ever made at all) it is often hard for a patient
who has become accustomed to constant bed rest to get used to a new
lifestyle.
The root of all the evils that I have described to you is inactivity. Idle-
ness is not only a vice—with our patients, we refer to it as “unsocial char-
acteristics”—but also the beginning of nonsense. Life is activity! That
holds for physical as well as mental life. Powers that are not used diminish,
disappear. Liveliness is only conserved through activity; the latter is the
basis for all achievement. In the case of some psychoses where there is
already a heightened excitability, the lack of activity serves to channel this
excitability in a deviant direction, in manners, stereotypes, mischief, col-
lecting, aimless running around, pestering others. An experienced psychia-
trist once put it this way, “A human being never does nothing—if he does
nothing useful, then he will do something useless.” We can add to this, he
will at least think something useless, something deviant. Successful activity
breeds satisfaction, internal and external calm; inactive loafing around
 Simon, Active Therapy in the Lunatic Facility — 273
breeds bad moods, moroseness, irritability. These, in turn, lead again and
again to frequent conflicts with others, to quarrels in words and actions, to
continued and loud grumbling and talking. The awful milieu of our earlier
“disruptive units,” about which more will be said later, arose out of con-
centrating numerous of these inactive patients together.
In the foreground of patient activity must be, as it has always been,
activity in the open, with garden and field work. I don’t need to justify this
here. Along with this, the second most important activity and involving the
largest number of patients is work toward the maintenance of the patient
ward and facility, i.e., in the kitchen, laundry, the estate, poultry breeding,
and offices. Whatever task can be done by someone who is sick is not to be
done by someone who is healthy. Every psychiatric facility has had work-
shops and craftwork rooms of various kinds for quite a long time. There is
hardly a single skilled trade that cannot be carried out on the premises. . . .
The therapeutic moment must stand at center stage in all the activities
for patients, and for the physician, the economic value of the work is not
the thing that matters in the first instance. But an attending physician will
always make sure that the labor force is, as much as possible, being put to
good use. It is also therapeutically important that most patients have a feel
for whether the work they are assigned serves a purpose or not. Only in the
former case will they be able to arrive at and attain a mental relationship
with and interest in the work. Moreover, the entire treatment plan must
start with the assumption of reintroducing a healthy logic into the life and
mental world of the patient; and a first principle of a healthy logic is, that
what one does must have a sense and purpose.
On the other hand, in order to move them forward, the patient must
be pushed to the upper limits of their abilities in their activities. For only in
this way can we gradually achieve progress. . . . The work assigned a patient,
therefore, should be real and serious. It is better and more beneficial to
press a patient to do two hours a day of serious, genuine labor than allow-
ing him to stand or run around as a dawdling member of a work detail. On
the one hand, the need to not strain the patient’s existing energies and
capabilities, and, on the other, to maintain a high standard together deter-
mine a careful individualization of the entire occupational therapy. Herein
lies one of the most important as well as most difficult tasks for the psychi-
atrist. Every aspect of mental life needs to be taken into consideration: the
degree of mental clarity or confusion, liveliness or inhibition, the coherence
274 — The New Focus on the Body
or distractedness of thought, the attention, the fatigability, and lastly—be
careful with this one—the affective attitude. . . . The physician must, above
all else, take into consideration all the mental abilities that are still within
the patient which can be used and developed in order to school the patient
from purely mechanical tasks to once again more independent thinking and
action, to attentiveness, concentration and finally again to a certain meas-
ure of responsibility—to be precise, through goal-oriented training and
practice in all aspects of mental life. And even after going to such lengths
to get individual patients to work, this is not the end, but rather the begin-
ning, of psychological therapy for us.
This effort at leading each patient to higher stages of achievement and
capability is reminiscent of the way in which schooling is organized,
whereby pupils are distributed according to their different levels of progress
and ability. . . .
First Stage: simplest tasks not requiring any particular degree of inde-
pendence and concentration. Lending a hand by helping to carry a basket
or other object; also, for physically robust patients, routine help in getting
meals, carrying laundry. Gradually letting the patients get an object on their
own and to bring it to a particular place alone. The simplest domestic work,
such as dusting of furniture, doors, and windows and polishing. . . .
Second Stage: mechanical work making minimal demands on attention
and vigor. Simple work details in landscaping, that last for a longer period
of time, so that the patients have time to get used to being part of a “train-
ing colony.” [Also] . . . straightforward basket weaving. Spooling for weav-
ing. . . . Simple, feminine, physical labor, such us darning and hemming of
clothes, towels, etc. . . .
Third Stage: work demanding moderate attention, vigor, and intelli-
gence. This involves most of the work in details in agriculture and garden-
ing as well as in institutional maintenance (field cultivation, harvesting,
cleaning stalls, transporting coal, walkway construction and upkeep); gar-
den work with the exception of special tasks for which lengthier training is
necessary. . . .
Fourth Stage: work demanding good attention and a measure of normal
ability to reflect. Skilled agricultural and garden work, planting and raising
of vegetable cuttings, glasshouse work, servicing of lawnmowers. Weed
work, where attention and care are required, as in the case of young plants.
Independent feeding and tending of animals (pig stalls, poultry pens).
 “Insulin and I” — 275
Mowing. Skilled work in workshops. Preparing new laundry and clothes in
the seamstress shop; more refined physical labor of all kinds. . . .
Fifth Stage: full, normal work capacity of a healthy person from the same
background. Here belongs the rehabilitation of acute illnesses, some mod-
erate imbeciles, epileptics in an asymptomatic phase, as well as many para-
noids (insofar as their outlandish thinking does not hinder their ability to
perform and control themselves). . . . It is best to give such patients inde-
pendent responsibility and appropriate positions of trust, as far this can be
tolerated, e.g., as leader of a small work detail, for errands and tasks outside
the facility, telephone and front desk service. Also the “unit elders” in
“staff-free units” belong here.

From Hermann Simon, Aktivere Krankenbehandlung in der Irrenanstalt (Berlin: Wal-

ter de Gruyter, 1929), 6–7, 16–27. With kind permission of Walter de Gruyter
Press. Translated by Greg Eghigian.

Anonymous
“Insulin and I”
(1940)

Insulin coma therapy (also known as insulin shock therapy) was

developed by the Austrian neurophysiologist and psychiatrist Man-
fred Sakel (1900–1957) around 1930. The labor-intensive treat-
ment generally involved giving psychotic patients daily injections of
ever higher doses of insulin until they fell into a hypoglycemic
coma. Patients would then be brought back to consciousness with a
sugar solution. A typical regimen might involve prompting five or
six comas a week for several weeks or even months, with psychia-
trists reporting that many patients’ symptoms gradually disap-
peared. While various theories were put forward to explain the
phenomenon, there was no agreement on the mechanism behind
the treatment’s efficacy. By 1941, 72 percent of all American psy-
chiatric facilities reported using the treatment. The following first-
276 — The New Focus on the Body
person narrative comes from a former patient’s description of her
experience with insulin shock therapy; the statement was given
before a medical meeting of the then Westchester Division of New
York Hospitals (formerly known as Bloomingdale).

When you pick up the New York Times and read that you are one of four
insane patients completely cured by insulin treatment in an important men-
tal hospital, you can assume three attitudes. You can be indignant at being
called insane; you can stick out your chest and say: “Well, I see I made the
Times this morning, even if I did have to go crazy to do it!” Or you can say:
“What a lucky girl am I—hooray for insulin!”
I couldn’t take the first attitude, for I should not be hurt at all to be
called insane; having lived for nearly a year among the mentally ill. I have
found most of them interesting, some quite entertaining, and I don’t think
I missed a great deal away from the mentally balanced. To take the second,
would only be the Irish in me. The third, of course, would be easy. I am a
lucky girl and do say “Hooray for insulin!”
There has been so much written about insanity that for me to add any-
thing would be like telling the old, old story. Clifford Beers found his mind
and let us know it.* Seabrook came out of the alcohol into the here, and the
process, I guess, wasn’t much fun; it never is. There have been “Outward
Rooms” and “Closed Doors” and they were not tales by idiots signifying
nothing.† They were vital experiences of sensitive people who had the
courage to publish their worst. If you bought the books and read them
because you wanted a new thrill I could very peacefully see you hanged. If
you read them because you wanted to go on a maudlin sentimental binge at
the expense of the ineffective other half, I think I should be nauseated if I
ever met you. If, however, reading them made you think a little more of the
important things in life and a little less of those not so much so, if you

*Editor’s note: The American Clifford Beers (1876–1943) published A Mind that
Found Itself in 1908, an autobiographical book about his institutionalization for and
his recovery from manic depression. Following the book’s success, Beers became a
leading advocate for people with psychiatric disabilities.
†
Editor’s note: The author is referring here to William Seabrook’s Asylum (1935),
Millen Brand’s The Outward Room (1937), and Margaret Prescott Montague’s
Closed Doors (1934).
 “Insulin and I” — 277
remembered to send a flower to a friend occasionally and could tear your-
self away from the stock market long enough to really listen to the troubles
of your office boy, then I think these writers made no mistake in baring
their souls to you. Insanity is certainly a disease of the mind, but more truly
a disease of the soul. I can’t say I ever thought it did one much good if he
had a soul to go flaunting it about. If it was good, some one would just try
to take it away, and if it was rotten, there would always be some one around
to make it a little more decadent. I have always thought the best thing to
do about souls is to shut up and bear them in peace or pain depending, of
course, on the kind you have. If yours is particularly painful you do need a
doctor, and a good one. Don’t ask advice of your friend who reads Freud or
buys mentally helpful periodicals at the newsstand. He will tell tales to
make your hair stand on end, and what to do if it does. He will toss off
Schizophrenia, Dementia Praecox, and Manic Depressive like so many A, B,
C’s, then run into the opposite direction when you need real help. For me
to dissertate on symptoms, progress, and convalescence of these diseases
would be like calling in a craftsman to do an artist’s work. I have no techni-
cal knowledge of mental illness and too much respect for those who have,
to take pot-shots and besides, I don’t like to talk about my operations. I have
always felt the same way about them as I do about labor pains or digging a
trench for the peonies. ’Twas “feelthy” work, but peonies are so beautiful.
The peonies are particularly beautiful today. So is the blue Long Island
Sound which laps peacefully at my garden’s edge. The red geraniums in the
pots on the terrace are flaming in the sun. I have found the world just as
beautiful as when I left it ten months ago. I would much rather talk about
your garden and mine, but I can’t: I must talk about insulin—a magic drug,
and about the intelligence of those who had the foresight to use it.
I did lose my mind—people do. I don’t think it would be particularly
interesting to anyone beside my friend the doctor—how I did, and why.
Suffice it to say that I do not remember being taken to the hospital, nor did
I recognize I was in one for eight months. I lived an Alice-in-Wonderland
sort of existence in a world of my own hallucinations, traveled in many
lands, and had so many vivid experiences that when I did get well, I don’t
see why I wasn’t a complete wreck.
One morning when a nurse said I was to go downstairs for treatment
my heart went down into my boots. What more horrible things could they
have to offer? Continuous baths and cold packs were things to beg to be
278 — The New Focus on the Body
taken out of. Another treatment could only be worse. I tried to influence a
young student nurse to get my clothes out of the closet and dress me,
thinking they all might forget me, but ah no, things are not done that way
in my hospital and when the appointed time came, down I went with a spe-
cial nurse, flapping along the corridors in my dilapidated mules. There were
two beds in the treatment room, two nurses, and a man sitting at a desk.
When they took me over to him, he said, “Put her in a pack,” and I did not
think he could ever be a friend. So the biggest and smallest nurse came and
wrapped me in swaddling clothes. I thought I smelled chloroform and was
floating away to be delivered of a child, and was quite sure of this when they
injected the insulin in my hip. It was just another dose of pituitrin to me. I
shall never forget the little nurse who finally released me from the pack and
put me back in a nice dry bed. Large cups of lemonade were given me and
finally lunch came in on a tray. The patient in the other bed sat up and ate
all her lunch, but I was terrified to eat mine and needed a lot of help from
the nurse. By this time I was simply drenched in perspiration and couldn’t
have felt more like a clam. This, caused by the insulin, is one of the most
unpleasant things about it. I was rubbed with alcohol and my special nurse
took me upstairs.
During the afternoon I was fed milk chocolate and huge glasses of
orange juice filled with glucose to replace the sugar content which the
insulin removes. Every day, except Sunday, for six weeks I went down to
that room to repeat the same treatment, and every day I dreaded it just as
much, if not more. I was never given another pack, but I had so many dis-
torted ideas about insulin that the effect of it was horrible to me. I would
get into the bed very quietly thinking that if I could stay like that nothing
would happen, but soon little beads of perspiration would begin to come
out on my arms and I would know that I was lost. I was dissolving away
into nothingness. The soap with which I bathed was oozing out of my
pores and making me deathly sick; my distorted mind was taking me
through most harrowing experiences. I would often come out of this to find
myself tied in bed and would count her my guardian angel who untied the
knots and released me.
The man, whom I soon learned to call doctor, would come over to my
bed and ask if I didn’t want to go out and play ping-pong or badminton. I
would have played football to get out of there. And I did go out and play
badminton every afternoon with a pocket-full of milk chocolate. At four in
 “Insulin and I” — 279
the afternoon my nurse and I would go back to the treatment room for
nourishment. More orange juice with glucose and more chocolate. Some-
times the nurses would have boxes of bonbons that patients had given
them. I remember on Valentine’s Day being offered a gay candy heart from
one of the boxes and being so thrilled over it.
It was about this time that, with some misgiving, I was transferred to
another hall. What would it be like? Who would be there and what would
they do to me?
I found it to be a hall with beautiful flowers, kind and helpful nurses,
and a patient I once knew. Even though she did not remember me, my rec-
ognizing her helped me a little to place myself and be aware of where I was.
Insulin treatments still went on, and I was still trying to devise ways in
which to get out of them. Some mornings, like a school child, I would carry
a few flowers in my hand to bribe the teacher. But doctors and nurses are
made of sterner stuff. The insulin was never forgotten and my mornings
were hell. Into a rocking, rolling sea of intangibles to come up out of it shiv-
ering and shaking and freezing to death. A hot bath and clean clothes, the
joy of all joys. I spent my afternoons playing badminton or walking with my
nurse. When I was on the hall I sat in a chair and stayed there, being afraid
to move until someone called me to meals. I didn’t make anything in the
occupation therapy department, but sat and looked at the baskets they
hoped I might weave. Every time the door-bell rang in the building, I prayed
it was a gymnasium instructor calling for me to play games. These girls
were bright, gay, and well dressed. The sight of normal people in good
clothes does much for the morale of the mental patient. In the gym, my
nurse would sit on one of the window seats while I played badminton or
ping-pong. I played very badly, but liked being there so much more than on
the hall where I never seemed to know what to do, or in occupation where
I certainly did not occupate.
February 22, when I went to the insulin room, my doctor said I was to
have one more dose of insulin on the twenty-third. This horrible business
was to be over next day! I heard that a doctor I knew in New York was com-
ing to see me. It seemed strange that I might go upstairs to see if he were
real. I heard them talking about a tea-dance, and I asked to go. I wanted to
see if it were real too.
That day after the insulin my nurse bathed and dressed me and the two
little nurses from the insulin room came running into my room with rouge,
280 — The New Focus on the Body
lip-stick, and powder. If I were going dancing, they were going to see that I
went with my best face forward. They were laughing and full of fun and as
interested as a mother sending her daughter to her first dance. I never quite
believed I was going to this party until I stepped into the ball-room where
an orchestra was playing good dance music and the room was filled with
gaily dressed people. It was the first time in seven months I had seen so
many men. We sat along the wall and had tea and sandwiches. My doctor
from the insulin room asked me to dance. He danced beautifully, but I felt
heavy and stiff. He said “Star Dust” was one of his favorites. All this music
was unfamiliar to me. Things that people had been dancing to all winter, I
supposed. I don’t know that I distinguished one from another, but I liked
the orchestra and I have always liked to dance.
I danced with a young nurse who told me about taking his patient to
hear the trials at the county court. He said he had always wanted to be a
lawyer.
After dancing I would go back to my nurse and sit with her and my sis-
ter who had driven over to see me. She kept telling me very definite things
about my own family. This was all surprising to me, as I had believed every-
one I had ever known was dead. Every time I would launch off into one of
my witless hallucinations, she would tell me that she would have to go
home if I couldn’t talk sense.
The thing I wanted to talk about most was the last insulin treatment
the next day. Was it really true? She assured me it was; the doctor had told
her I was to have no more. I could certainly endure the next treatment if it
was to be the last.
We finally found our hostess, one of the head nurses, and said good-
bye. Back on the hall I was given my supper from a tray and had just as
many strange complexes about food as I had six months ago, and certainly
must have tried the patience of the little student nurse who fed me. I went
to bed happy, thinking of tomorrow.
It must be understood that insulin does not affect every patient the
same way. It is not a dose of salts. Some of the patients who took it seemed
very sick, others were on halls that were not considered “bad.” They played
games well, did good work in occupation, and seemed alert. I was badly con-
fused until February 23.
That day when I woke up, there was no sleepy fluttering of the eyelids,
no yawning or stretching to pull myself awake. I just came alive with all
 “Insulin and I” — 281
cylinders in perfect working order. I went down for the last insulin injec-
tion, and it was just as horrible as it had always been. When it was over, I
came upstairs with my nurse, feeling as though I had had three glasses of
champagne. After a bath and clothes, we went out to walk. The world never
looked so beautiful. I couldn’t breathe enough of the air or look enough at
the sky. We walked and walked with the cool wind whipping my hair about
my face. It was like sailing on a September day when the blue water is full
of sun glint. We sat in one of the arbors while I smoked a cigarette, and I
talked and talked, making up for lost time. It seemed so strange to see cars
on the road beyond the fence. The world going on about its business as
usual. I felt well, I liked what I saw, and I was happy. That state of mind
never left me. My special nurse soon left and I was on my own. Saturdays
and Tuesdays I went out to tea with some member of my family and those
were gala days. It was such fun to go to the different shops to tea and be
brought up to date on all the news. I found I had missed a hurricane and a
war scare, and that Hitler had taken Czechoslovakia. All my conversations
started with “tell me.” I was soon moved to an open hall, which meant no
locked doors, more exercise, and more privileges. Here I was hailed by my
first name when I entered the dining room and was taken on for bridge and
Chinese checkers in the evening. I had a very attractive room and liked tak-
ing care of my own clothes again. It was nice having powder, perfume, and
lipstick where I could get at it. On the other halls everything is locked away,
and one must ask a nurse for everything. This never bothered me very
much, but I appreciated the change. In other words, I didn’t know what I
had missed until I was given something better. I began to knit socks and
went into the art room at occupation. Here in the next two months I made
two belts embroidered in wool, a wooden salad bowl, polished to a beauti-
ful patina, a pair of painted book-ends and some pottery. I loved this room.
The woman in charge was a charming person, helpful and encouraging, and
the patients turned out some excellent work.
In the afternoons we all went to the gymnasium and I began to play a
good game of badminton, getting into games with more seasoned players
which I certainly enjoyed. I would get back on the hall in time for a tub
before dinner. After dinner it was bridge or knitting, watching the others
play. Twice a week I went to the choral classes and enjoyed the singing. I
also began to play the piano again and found I played better than before I was
sick. Life on the hall was very pleasant. People were friendly and hospitable
282 — The New Focus on the Body
to newcomers. Voices were soft, gentle, and low, and consideration of oth-
ers seemed to be the main theme.
I left here soon to go to one of the cottages on the grounds. I was sorry
to go, but glad to know it meant advancement. This was a charming little
house, and I was teased a lot when I got what they called the royal suite, a
delightful room with green walls and rose damask curtains, maple furniture,
and pewter lamps. Those who planned my welfare couldn’t have been more
thoughtful.
At the cottage life went on much as before. There were ten patients and
one nurse in charge. Some of the patients had been on the other halls with
me, some had taken insulin and some had not. We had lots of fun talking
about the weird things we had done when we were very sick. In the morn-
ings we went to occupation, took a long walk, and had lunch. In the after-
noon it was badminton from three-thirty till five. Evenings were given over
to bridge. We were well-fed and well exercised. We were rubbed with salt,
put under the sun lamp and baked, then showered with hot and cold hoses.
Our social life was taken care of. Every day would bring more buds out on
trees, and I would look at the forsythia and make bets as to when it would
burst forth.
With all this we should have gotten well, and many of us did. We do
have a feeling of affection for those who went through it with us and those
who brought us out. Insulin did make me well, but the hospital and the
doctors and nurses connected with it are entirely responsible for my well-
being. One thinks of a hospital as a machine, of white linen efficiency and
disinfectants. The works are all there in my hospital. It is run by men and
women of intelligence and profound knowledge. They conduct their affairs
with grace and charm. If it is an insane asylum, it is one that I am proud to
have been in.
Insulin and I say hooray!

From Anonymous, “Insulin and I,” American Journal of Orthopsychiatry 10 (1940):

810–814. (© American Orthopsychiatric Association), reprinted with permission
of the American Orthopsychiatric Association.
 Freeman & Watts, “Psychosurgery during 1936–1946” — 283

Walter Freeman
(1895–1972)

and James W. Watts

(1904–1994)

“Psychosurgery during 1936–1946”

(1947)

If nineteenth-century neurology had helped convince many that

mental disorders were by and large brain diseases, neurologists,
often seemed unable to offer many treatment alternatives for dealing
with this reality. That began to change when the Portuguese neu-
rologist Egas Moniz (1874–1955) developed a surgical procedure
he called a “prefrontal leukotomy.” Evidence from pathological
anatomy, experiments on mammals, and wartime head injuries con-
vinced Moniz that the destruction of tissue in the prefrontal lobes
of the brain might cause the health of psychiatric patients to
improve. Designing a special wire knife, which he dubbed a “leuko-
tome,” he operated on his first patient on 27 December 1935. Years
later, in 1949, he received a Nobel Prize for his innovation.
Moniz’s work was closely followed by that of a professor of neu-
rology at George Washington University in the United States, Wal-
ter Freeman. Freeman and his colleague James Watts created their
own procedure and gave it the name lobotomy, in order to distin-
guish it from Moniz’s leukotomy. Until 1945, however, Freeman
himself actually had never performed a lobotomy. After first prac-
ticing on cadavers, he developed a new technique, one that he
believed would not require the assistance of a neurosurgeon. This
was the transorbital lobotomy, by which an ice pick was inserted
into the skull through the eye socket, tapped with a hammer, and
then moved around in order to destroy tissue. By the early-1950s,
Freeman was traveling the country, visiting asylums and teaching
the technique to eager staff. In the period between 1939 and 1951
alone, around eighteen thousand lobotomies were performed in the
United States.
284 — The New Focus on the Body
Psychosurgery was introduced into this country ten years ago, amid rum-
blings of disbelief and thunderings of disapproval. Its seems appropriate
now that a survey of results of the first decade be presented.
It was the experimental work of a group of investigators in Yale Uni-
versity that started Egas Moniz on the surgical treatment of mental disor-
ders. Jacobsen, in association with Fulton, noted a profound alteration in
response to frustration in the chimpanzee with both front poles excised.
Before operation, if the animal made a few mistakes, he would scream with
rage, urinate and defecate in the cage, roll in the feces, shake the bars and
refuse to continue the experiments. After the operation the same animal
would continue in the experimental situation long beyond the patience of
the examiner, making mistake after mistake, without the least indication of
being upset emotionally.
At about the same time Brickner published an extensive report on the
case of a man whose frontal lobes had been removed several years before
because of a tumor. This man was of average intelligence, as shown by var-
ious tests following the operation, but the striking thing about him was his
complete lack of self consciousness and his obliviousness to the seriousness
of his own predicament. While Brickner did not mention worry by name,
his patient was obviously incapable of exercising this most human of intel-
lectual-emotional exercises.
Egas Moniz had theories of his own, but they tied in well with the find-
ings of Fulton and Jacobsen and of Brickner; therefore he and Almeida Lima
commenced operating on psychotic patients and first reported their results
in the spring of 1936. Fulton called our attention to these reports, and by
the end of 1936 we completed our first series of operations on 20 patients.
Seven of these patients had to have a second operation because of relapse,
and 2 of them underwent three operations before the psychosis could be
overcome. However, a recent check on this first series revealed that 1
patient died after operation and 5 more since, including 1 by suicide. Of the
14 living patients, 4 are employed and 4 are keeping house; 4 are living at
home, and only 2 are in institutions (appendix).
At the time of our first reports we emphasized the need of a long period
of observation before definitive conclusions could be drawn. Up to the pres-
ent time we have kept in touch with all our patients, now numbering well
over 400, and the results in succeeding years are on the whole similar to
those in the first series. By means of refinements in the technic of pre-
 Freeman & Watts, “Psychosurgery during 1936–1946” — 285
frontal lobotomy, we are able to secure a higher percentage of successful
results in relatively favorable cases; and, knowing what could be accom-
plished in these, we have undertaken operation in a large number of unfa-
vorable cases. Consequently, the percentages in the various categories of
social adequacy have remained about the same over several years.
In prefrontal lobotomy the surgeon incises the white matter in both
frontal lobes in such a way as to sever the connections between the thala-
mus and the frontal pole. From the time of our first operations we have
asked ourselves what the operation does to the psychosis to make it clear
up. We vividly recall the case of a young woman who was responding with
intense fear to her hallucinations. They were of the most disagreeable
kind, the voice calling her a dog and threatening her with hell fire. She was
in a panic, and her attention could hardly be gained. Within a few hours
after operation she described the same experiences but in a subdued tone
of voice, as though they were hardly worth mentioning. A few days later,
when questioned about the voices, she replied: “Voices? No. My ears have
gone dead.” This case illustrates the bleaching of the emotional tone and
the quieting of anxiety that almost always accompany prefrontal lobotomy.
In fact, of all the symptoms of mental disorder, emotional tension has
undergone the most profound alteration after prefrontal lobotomy. This
does not mean that these patients are apathetic, lacking all emotion. As a
matter of fact, as they recover from the post-operative inertia, they are
fairly responsive, sometimes more than they were before they became sick;
but the emotion attaches itself to external happenings rather to inner expe-
riences. Patients who have been operated on are usually cheerful, respon-
sive, affectionate, and unreserved. They are outspoken, often critical of
others and lacking in embarrassment. For the first few weeks or months
they are rather childlike in their attitudes and behavior. They require more
than the ordinary motivation to accomplish and are satisfied with some-
thing less than perfection. They tend to procrastinate, to make up their
minds too quickly and to enunciate opinions without considering the var-
ious implications. Some patients are distractible, others have single track
minds; some are indolent, others are human dynamos. The most striking
and constant change from the preoperative personality lies in a certain
unselfconsciousness, and this applies both to the patient’s own body and
to his total self as a social unit. The patient emerges from operation with
an immature personality that is at first poorly equipped for maintaining
286 — The New Focus on the Body
him in a competitive society; but with the passage of time there is pro-
gressive improvement, so that in about one-half the cases earning a living
again becomes possible.
On the basis of these experiences, we have advanced the hypothesis
that the frontal lobes are especially concerned with foresight and insight
and that the emotional component associated with these functions is sup-
plied by the thalamus. When the thalamic connections are severed, the
functions of foresight and insight suffer temporary obliteration, and even in
the later course of recovery are never as completely endowed with feeling
tone as they were before. A modicum of function is preserved, because the
direct connections are not completely severed and because indirect con-
nections probably also exist. Foresight and insight are two very important
functions for any person living in a complex society. One may well ask
whether the surgeon is justified in depriving a patient of these functions
even for the sake of relieving his psychosis. We believe the surgeon would
be entirely justified if it could be shown that the patient became psychotic
because of perversions of these same functions of foresight and insight,
together with the attachment of an abnormal emotional tone.
When one studies a psychotic patient with these functions in mind, it
is not so difficult, if the case is not so far advanced, to determine the fact
that many of the symptoms of the psychosis may indeed be attributed to
pathologic selfconsciousness. Why otherwise would a patient believe that
he was being kept under surveillance by the F.B.I.; that German spies were
entering his room, using thought control on him, putting dope in his food
or accusing him of sexual perversions? These ideas are intensely personal to
him and preoccupy his mind to the exclusion of all rational, coherent
thought process. Or take a patient who has a string of complaints as long
as his arm concerning his stomach and his bowels, his heart and his head.
Here is a person, also, whose function of consciousness of the self has gone
beyond normal limits into a state of hypochondriasis. His attention
becomes concentrated on his various organs to the exclusion of everything
else. In both cases there is also a distressing concern for the future; not only
what “they” are going to do to him, but also in regard to the prospects of
the ulcer, cancer, or heart trouble. Above all, there is the emotional com-
ponent which invests the symptoms and the ideas with a disabling force
and completely prevents the patient’s adaptation to the realities of exis-
tence. Such persons are sentient rather than rational beings. They live with
 Freeman & Watts, “Psychosurgery during 1936–1946” — 287
their emotion concentrated on themselves, with an admixture of self pity or
guilt that induces invalidism or, at the last extremity, suicide.
Prefrontal lobotomy cuts off the emotional component concerned with
these ideas. It relieves the symptom of mental pain. In temporarily abolish-
ing foresight and insight, the operation breaks the vicious circle of preoc-
cupation, emotional tension and imagination that makes the suspected
disease or persecution much more serious than any reality could be. It
brings the patient back to earth and the enjoyments thereof.
The past decade has seen a certain vindication of our ideas on the sub-
ject of prefrontal lobotomy. Even in our first papers we cautioned against
going to extremes. Now, at the beginning of the second decade, we would
reiterate these cautions. Prefrontal lobotomy is an operation of last resort.
It should be performed only on those patients who no longer have a rea-
sonable hope of spontaneous recovery. It should be done only in cases of
threatened disability or suicide, and only after conservative measures have
failed. It should be done with the full appreciation of the changes in per-
sonality that will inevitably be brought about in the patient if the operation
is to succeed, and with a knowledge of possible unfavorable results, such as
persistent inertia, convulsive seizures, incontinence, and aggressive misbe-
havior. At the same time, prefrontal lobotomy should be performed while
the patient is still fighting his disease, in other words, while the emotional
tension is still present to a considerable degree. When emotion subsides
and the patient accepts his dream world in lieu of reality, surrenders to his
fantasies, then there is little that surgery can accomplish. It has been sug-
gested that if a patient with dementia praecox fails to improve after a year
prefrontal lobotomy should be considered. In view of the poor prognosis of
dementia praecox, we should be inclined to accept this idea. In our cases in
which operation was performed within the first two years of illness the per-
centage of good results was 85, whereas of those cases in which operation
was done after two to thirty years of illness good results were only obtained
in 31 per cent.
The types of patients who respond best to prefrontal lobotomy are
those with the obsession-tension states, with or without compulsions, and
the chronic anxiety syndromes, with or without hysterical conversion.
Twenty years of invalidism can vanish in a few weeks. Involutional depres-
sions also clear up in a goodly percentage. Schizophrenic states are strik-
ingly modified if the patient is excited, resistive, assaultive, and disturbed.
288 — The New Focus on the Body
The quiet, deteriorated patients are usually unchanged. Alcoholic, psycho-
pathic, and epileptic patients, criminals and patients with organic diseases
of the brain are seldom benefited.
Prefrontal lobotomy is being adopted in many parts of the world. The
war interfered with the development of the procedure in continental
Europe, so that the United States and Great Britain got a head start espe-
cially so far as detailed studies are concerned. Portugal and Italy, which
had been in the forefront, dropped behind. Scattered reports have come
from various Latin American republics; from Sweden and Czechoslovakia;
from India, New Zealand, and Hawaii. More enthusiasm seems to be pres-
ent in England than anywhere else. McKissock states in April 1946 that
he had personally performed 500 operations, and in the June 1946 issue
of the Proceedings of the Royal Society of Medicine there are statistics on more
than 800 cases. In this country, we should estimate that up to the present
time approximately 2000 lobotomies have been performed. A recent sur-
vey by Brody and Moore called attention to the rather great similarity of
reports from various clinics in the percentage of patients who derive ben-
efit from the operation. In round figures, one-third recover, one-third
improve, and one-third fail to improve. There are variations from one
investigator to another and from one disease to another, but the results are
sufficiently good to warrant the use of prefrontal lobotomy on a large scale
for the relief of the very serious and chronic forms of mental disease that
keep the back wards of the psychiatric hospital filled to capacity and
beyond.
We would close this review of prefrontal lobotomy by calling attention
to its use in the treatment of pain due to organic disease. In case of an incur-
able illness, such as cancer, or of persistent pain in a phantom limb,
intractable causalgia or the lightning pains of arrested tabes, the physician
is likely to give up too easily and to prescribe narcotics, to the ultimate
detriment of the patient with long-standing illness. A year ago we reported
experiences in the relief of long-standing pain with prefrontal lobotomy. It
would seem that in cases of this condition, as in the cases of purely mental
disorders, it is the emotional component, the consciousness of the part and
the anticipation of the future disability and death that contribute to the dis-
tress of the patient. In many cases the attitude of the patient toward his dis-
ease is more disabling than the disease itself; the fear of pain, greater than
the pain. With prefrontal lobotomy the physician now has it in his power
 Freeman & Watts, “Psychosurgery during 1936–1946” — 289
to relieve the fear, the anticipation, and to render the illness more tolerable
to the patient. Since this can be done without significant impairment of
intellectual capacity, it would seem that prefrontal lobotomy might be a
very considerable boon to the large number of patients whose life will not
be long but will, nevertheless, be made miserable by suffering. The physi-
cian cannot be criticized for recommending prefrontal lobotomy in order to
secure a certain euphoria for those patients who have only pain and death
to look forward to.

Appendix

The 20 cases in which operation was performed in 1936 were reported in

1938. A brief follow-up report as of September 1946, approximately ten
years after the first lobotomy, is now given. All the patients have been kept
under rather close observation at intervals of a year or less. The same case
numbers are used.
Case 1.—A housewife aged 63 had a history of agitated depression of
one year’s duration, with two previous nervous breakdowns. After pre-
frontal lobotomy she quieted down, went out socially, drove her car, kept
the household accounts, enjoyed her home but took little responsibility.
She had several epileptic seizures, fracturing one of her wrists in one of
them. In 1941 she died of pneumonia. Her husband wrote that the last five
years were the happiest of her life.
Case 2.—A woman aged 59, a bookkeeper, had agitated depression of
six months’ duration, probably complicated by intoxication with sedatives.
Prompt recovery followed prefrontal lobotomy, with return to work in
three months. She continued this work for eight years, until her retirement
because of age, and then returned to her office to help out during the war.
She finally retired in June 1946 and has been living comfortably at home.
Case 3.—A housewife aged 34 had obsessive preoccupations, depres-
sion, and suicidal ideas of three years’ duration. The first lobotomy was per-
formed in December 1936, with little improvement; the second, in
September 1937, with no change, and the third, in 1941, with extreme flat-
tening of emotional life. She presents extreme indolence, petulance, and
puerility and assumes no responsibility for the care of the home. She pres-
ents a rather pleasant front but has a sterile intellectual life. She is cared for
at home by her mother.
290 — The New Focus on the Body
Case 4.—A housewife aged 49 had involutional depression of one
years’ duration (with a history of three previous attacks) and organic
changes caused by a nearly successful suicidal attempt with gas. After
lobotomy she continued to show apathy, loss of memory and other signs of
organic disease of the brain. She had frequent convulsion and incontinence.
She died in status epilepticus in 1944. Autopsy showed minimal operative
lesions (all lobotomies in 1936 were done by the Egas Moniz “core” tech-
nic), but there were extensive cortical softening at the base of the frontal
and temporal lobes and necrosis of the globus pallidus.
Case 5.—A housewife aged 35 had a history of depression and agitation
of four years’ duration and three suicidal attempts. She benefited only tem-
porarily from the operation, failed to make a satisfactory adjustment at
home or on the farm and finally committed suicide in 1940. Autopsy was
not performed.
Case 6.—A housewife aged 60, with agitated depression, died on the
sixth post-operative day of hemorrhage. Autopsy was not performed.
Case 7.—A business man aged 59, with a history of involutional
depression of nine years’ duration, improved briefly after lobotomy but
relapsed before he could return to his office. A second lobotomy was under-
taken by a different surgeon in 1938, and the patient emerged permanently
relieved of his depression but with a boisterous, arrogant, and extravagant
nature that required institutionalization. His condition remains
unchanged, after eight years.
Case 8.—A housewife aged 62 had a history of hypochondria of seven-
teen years’ duration with superimposed agitated depression for two years.
A year after operation she found part-time employment as a practical nurse
and continued in this work until 1945, when she went to live with her
daughter. She is fat, jolly, and outspoken and is said to be “quite a worker
for her age.” The visceral complaints cleared up.
Case 9.—A housewife aged 48, with involutional depression of two
years’ duration, had had many admissions to the hospital for abdominal
complaints. No improvement followed the first lobotomy, in November
1936. The second operation was performed in March 1937, with relief.
However, the patient was indolent and sarcastic and was subject to out-
bursts of anger, which made it necessary to confine her in an institution for
eighteen months. After this she resumed her household duties, cared for
her grandchildren during the war and still performs most of the domestic
 Freeman & Watts, “Psychosurgery during 1936–1946” — 291
work in her daughter’s home. On several occasions she has had fleeting
depressions, only one of which was sufficiently severe to require treatment;
two electroshocks were sufficient.
Case 10.—A housewife aged 60, with agitated depression of seven
years’ duration, had transitory improvement after the first lobotomy, in
November 1936. At the second operation, in March 1937, severe bleeding
was encountered, and the operation was not completed. The patient
remained unimproved and died of a heart attack the following July. Autopsy
was not performed.
Case 11.—A secretary aged 32, with catatonic schizophrenia of two
months’ duration and a history of a previous attack in 1934, lasting only a
month, recovered rapidly, and apparently completely, after lobotomy and
returned to her position. She was unable to continue because of return of
emotional tension, followed by another catatonic attack, for which she was
hospitalized in July 1937. Insulin and metrazol shock treatments failed to
induce recovery; her family refused permission for further operation, and
she remains in the hospital, greatly deteriorated, fat, and inaccessible.
Case 12.—A stenographer aged 25 entered a catatonic state in July
1936 and showed no change after unilateral prefrontal lobotomy. When
operation was performed on the opposite side, she “woke on the table.” She
improved slowly; in a year she took a course in interior decorating but did
nothing constructive with it, then returned to work as a stenographer and
continued in this until 1942, when she again lapsed into a catatonic state.
More extensive prefrontal lobotomy again abolished the condition, but she
made a slow and imperfect recovery and was rather hostile to her family.
After two years she found a clerical position and a separate domicile and
continued living in this way for over a year; but when her parents became
ill she returned home and has cared for them in small ways for the past
year.
Case 13.—A cement finisher aged 33 had obsessive preoccupation with
his heart and general exhaustion of eighteen months’ duration. After pre-
frontal lobotomy he was euphoric but soon relapsed. Two years later, how-
ever, he was able to resume laboring work part time. His adjustment
improved with time, and for the past four years he has been steadily
employed as janitor at a school, where he is highly thought of.
Case 14.—A housewife aged 30 had agitation, feelings of unreality and
probably hallucinations of six years’ duration. After prefrontal lobotomy
292 — The New Focus on the Body
she made an erratic adjustment and was in and out of hospitals for four
years. After that she was divorced, and since remarried and writes enthusi-
astically of her new life.
Case 15.—A stenographer aged 42 had an acute onset of catatonic
stupor in the course of rheumatic heart disease of many years’ duration.
Both the mental symptoms and the cardiac irregularity cleared up briefly
after prefrontal lobotomy, but the improvement was not sustained. She
died of congestive heart failure in April 1937 with recrudescence of men-
tal symptoms.
Case 16.—A housewife aged 60 had a history of obsessive-compulsive
neurosis dating back thirty-six years, with intervals of good health, but with
complete disability of four years’ duration. Prefrontal lobotomy was fol-
lowed by temporary euphoria and later return of symptoms. The second
lobotomy, in March 1937, was followed by immediate disappearance of the
emotional toning, but with persistence of the compulsive washing and
brushing for at least three years. She presented marked increase in weight
and was outspoken, tactless, and disagreeable with her family. There has
been steady improvement over the years, although she still shakes her skirt
at imaginary dirt. She recently celebrated her seventieth birthday and is
cheerful, outspoken, and rolypoly.
Case 17.—A telephone operator aged 33, with obsessive syphilophobia
of twelve years’ duration, obtained partial relief from operation and was able
to return to work. After a broken engagement her fears returned, and a sec-
ond lobotomy was performed in 1938. She immediately lost her fears but
became indolent and talkative in a silly, vapid way, was too distractible to
continue at her work, helped out on a farm for a year or two and for the past
two years has been steadily employed in a mill. She writes in a rather child-
ish way of her plans for getting married.
Case 18.—An attorney aged 37 had a history of severe psychoneurosis
complicated with alcoholism of many years’ duration. Prefrontal lobotomy
relieved his fears but not his alcoholism, and he made an erratic adjustment
for several years, enlisting in the Army and serving with the military police
until his active service was terminated, after the third court-martial, with a
psychiatric discharge. Since then he has been performing legal work for the
Government, with increasingly less frequent alcoholic bouts.
Case 19.—A bookbinder aged 40 had been hypochondriacal since girl-
hood, with a record of twelve to eighteen abdominal operations. She had
 Freeman & Watts, “Psychosurgery during 1936–1946” — 293
been bedridden for two years. She walked on the third post-operative day
and thereafter recovered slowly, but surely. She has been employed for the
past seven years at her old job. She still complains when asked about her
symptoms but never mentions them otherwise.
Case 20.—A housewife aged 40, with attacks of manic-depressive psy-
chosis at long intervals, recovered in about a year from an episode in 1929
and was free for seven years. During the attack in 1936 she attempted sui-
cide, sustained severe internal injuries but had only fleeting relief from
depression. Prefrontal lobotomy was carried out in December 1936, with
fleeting improvement. The following spring she again attempted suicide
and sustained extensive burns. The clinical picture was decidedly schizoid
at that time, and she was maintained in a psychiatric hospital for over a
year. Finally, she received a brief course of metrazol shock therapy and
recovered promptly. She has been taking care of her household satisfacto-
rily for the past five years in spite of major domestic difficulties.

From Walter Freeman and James W. Watts, “Psychosurgery during 1936–1946,”

Archives of Neurology and Psychiatry 58 (1947): 417–425. Copyright © 1947, Amer-
ican Medical Association. All rights reserved.
 Psychiatric Eugenics
in Nazi Germany

Fritz Lenz
(1887–1976)

Human Selection and Race Hygiene

(1921)

Adolf Hitler (1889–1945) and the Nazi Party borrowed heavily

from earlier racist and eugenic thinkers. Social Darwinism and
eugenics advocates had begun to consider what they believed to be
the racial implications of natural selection already in the nineteenth
century. In Germany, Alfred Ploetz (1860–1940) and Wilhelm
Schallmayer (1857–1919) developed the idea of “race hygiene,” a
program calling for the use of science, medicine, and public policy
to promote what they considered to be racial health. And in 1921,
Erwin Baur (1875–1933), Eugen Fischer (1874–1967), and Fritz
Lenz published Outline of Human Genetics and Race Hygiene, a highly
acclaimed synthesis of genetics, anthropology, and medicine. The
multivolume work quickly became the standard textbook in German
race hygiene throughout the 1920s and 1930s, going through five
editions between 1921 and 1940. We know that Hitler himself read
the second edition while he was serving a prison sentence in the
early 1920s.
Fritz Lenz, who authored volume 2 of the book, was a onetime
student of Alfred Ploetz. During World War I, he served as a
hygienist at a prisoner-of-war camp. He eventually rose to become

294
 Lenz, Human Selection and Race Hygiene — 295
head of the department of eugenics at the Kaiser-Wilhelm Institute
for Anthropology, serving as adviser to the government in the draft-
ing of the 1933 sterilization law (see the following document in this
volume). Lenz survived World War II and was hired afterward as a
professor of human heredity at the University of Göttingen.

Regarding the truly mentally ill, natural selection is also today still effective,
if only not to the same degree as in primitive cultures, where the mentally
ill regularly die early. And among native people today, one happens upon
the mentally ill far more seldomly than with us, where the insane are cared
for and protected. Without this care, most mentally ill would soon fall vic-
tim to all sorts of perils, particularly suicide, to which most of them are
inclined. A significant number of those predisposed to mental illness are
also released from facilities as cured or improved. They then often have the
opportunity to reproduce—apparently it has been assumed that this would
result in a steady increase in mental illnesses.
Whether the hereditarily mentally ill among us are increasing in num-
ber has not been statistically proved or disproved up to this point. The
growth in the number of intakes in asylums—for instance, in Bavaria, the
figure has risen from 24 per 100,000 residents in 1880 to 50 per 100,000
in 1910—can be explained primarily by the better care in facilities over
time. To be sure, paralysis has increased markedly over the past decades;
but this is of little interest to us here, since it comes from syphilis, an exter-
nal cause. At the same time, alcohol-related mental disorders were obvi-
ously not as prevalent in earlier times as they were in the decades before the
war. It is hardly probable, in fact just the opposite is likely the case, that
hereditary mental illnesses are on the rise. There is no valid, statistical evi-
dence for the contention that parents of the mentally ill or the mentally ill
themselves have relatively large numbers of children. Among the mentally
ill who are accommodated in facilities, two-thirds are single. From the per-
spective of selection, their institutionalization has an overwhelmingly pos-
itive impact; it takes away from the insane the very opportunity to
reproduce that they would have outside the facility.
It may be that conditions in simple peasant life may provide more
opportunities for the spread of predispositions to mental disorders than is
the case for us. My experience during the war with Russian and French
296 — Psychiatric Eugenics in Nazi Germany
prisoners of war appears to provide support for this. Among the Russians,
around 9 out of every 10,000 men fell ill with symptoms of schizophrenia
every year; but with the French, the figure was only 1.7. Since all told
around 14,000 prisoners were observed for three years, it could be only a
case of coincidence. The difference may also only be a result of the small
numbers that were examined in France, especially since the percentage of
those who were not [sic?] let into the army was fairly small. I would like to
accept that schizophrenic constitutions can be maintained and propagate
more easily under the simpler living conditions of the Russian peasant than
in western Europe. Of particular importance in this regard might be the sig-
nificant difference in the average age of marriage. Since in central and west-
ern Europe, the individual tends to enter into marriage around the end of
the third decade, at a time when the majority of cases of schizophrenia have
already broken out, only a small portion of those who are predisposed
reproduce. In eastern Europe, however, where marriage is entered into
already at the end of the second decade, carriers of this predisposition
marry in greater number; it is also that case that the state of mind of some
peasants leads a woman, even if she is feeble-minded due to illness, to have
more children.
Even if in past centuries numerous mentally ill fell victim to a barbaric
legal system, and still more simply degenerated into fools, I nevertheless
believe that under our present living conditions, natural selection (as it has
to do with predispositions to mental illness) is more intensive as it was
then. At any rate, present degeneration is frighteningly widespread.
According to the national census of 1910, 392 mentally ill and feeble-
minded per 100,000 residents were tallied, resulting in more than a quar-
ter million for the entire empire; and that naturally counted only those
known cases, whereas a tally according to general medical examination of
the population would have obviously resulted in a much higher figure. In
Switzerland, where surveys have been conducted under medical supervi-
sion, 800 to 1,000 mentally disturbed per 100,000 residents were found;
and the great majority clearly involve hereditary conditions, since those
arising from external causes like paralysis or delirium either quickly lead to
death or are generally soon neglected.
Actual idiocy will also certainly be wiped out as it was centuries ago. A
large segment among idiotic children die already during the first years of
life, and also those idiots who reach an older age naturally never marry and
 Lenz, Human Selection and Race Hygiene — 297
hardly reproduce out of wedlock. The reproduction of clearly feeble-minded
persons is also certainly lower than the average; sexual selection in this
regard is more effective in males than females. In general, the man must per-
form a trade in order to be able to marry. Feeble-minded girls, however, are
often married without any concern for their mental makeup; in addition,
they disproportionately often have illegitimate children, since they are
insufficiently able to foresee the consequences of sexual relations. In the
entire German Reich, there are 100,000–200,000 feeble-minded and more
than 75,000 idiots. Since a large share of the feeble-minded die relatively
early in life, the feeble-minded make up a greater portion of newborns than
of those later in life. At least 1–2 percent of all births might be feeble-
minded and 1/4 percent idiotic.
The lesser degrees of feeble-mindedness pose a greater danger to the fit-
ness of the race than those of a higher degree. Here the reason is the same
as with some organic nervous maladies. Due to their predisposition, the
moderately feeble-minded are directed toward taking on simple, physical
trades, and they have an above-average reproduction. The feeble-minded
are naturally the least accessible to deliberate birth control, and the high
mortality of their children is being more and more undermined by social
welfare measures. Thus, one must reckon with a continuing rise in partial
feeble-mindedness.
A share of the epileptics become feeble-minded already early on in their
youth, so that reproduction is out of the question. Another share has only
isolated attacks, however, and can propagate their predisposition. Accord-
ing to Echeverria, decades ago, the marriage of an epileptic brought only
around 3.3 children, of which 1.4 died early; thus, only 1.9 per marriage
grew to adulthood. And since many others never even enter into marriage,
their propagation is even less likely. Still, however, epilepsy today is extraor-
dinarily widespread. One must expect one epileptic per 300–400 residents,
and among newborns, still more.
The selection circumstances of psychopaths are quite involved. Among
prisoners of war, I observed pronounced hysteria decidedly more frequently
among Russians than among the French. Here a similar train of thought as
relates to schizophrenia might be appropriate. “The intensification and
accelerated tempo of the modern work process, the noise, the haste, and the
heightened responsibility, all this forces countless nerves to collapse, also
among the lower classes” (Rüdin). It can be rightly said, then, that natural
298 — Psychiatric Eugenics in Nazi Germany
selection works more toward the decline of nervous tendencies, the more
that external living conditions trigger predispositions.
When we hear reports from the Middle Ages of mass mental epi-
demics, child crusades, flagellations, dance epidemics, and epidemics of pos-
session, we mostly tend to believe that such things are no longer possible
in our enlightened age. In Russia, however, “possession” is still fairly com-
mon; there it is commonplace for someone to imagine that a snake or some
other reptile is inside him. In just the past centuries, Russia has experienced
horrible mental epidemics: self-mutilation, numerous self-immolations,
strangulation of co-religionists, and child murder based on superstition
were an integral part of Russian sects. And when we look around us with
open eyes, we can recognize, in some of the mental crazes during and after
the war, the effects of similar states of mind.
A significant number of all psychopaths die by their own hand. In the
German Reich before the war, around 20 suicides per 100,000 residents
annually were counted. Since numerous other cases occurred besides those
included in the statistics which were either hidden or counted as accidents,
it might have been that around 2–4 percent of all men died by their own
hand, whereas suicide was three times less frequent among women.
Although that segment of the population in which most suicides take place
is noteworthy for its higher intelligence (more advanced students, academ-
ics, artists), the selection effect of this phenomenon—one that is consider-
ably co-determined by modern living conditions—is, all told, certainly
overwhelmingly positive. Especially predispositions to manic-melancholic
mental disturbances, epilepsy, neurasthenia, and other psychopathies are
eradicated in this manner. Selection through suicide, therefore, tends in the
direction of strengthening the will to live and of a sanguine temperament
within the population.
Hardened criminals, who are almost consistently psychopathically pre-
disposed, on average today leave behind fewer offspring. According to Gor-
ing, habitual offenders in England married no less frequently than the rest
of the population (63 percent versus 62 percent), but they had only 3.5 off-
spring versus an average of 5.7. Moreover, 31.5 percent of their infants died
versus 15.6 percent within the general population. On the other hand, the
comparatively milder legal treatment today, in comparison with earlier
times, allows for the preservation of unsocial predispositions to a greater
extent than earlier.
 “The Law for the Prevention of Hereditarily Ill Offspring” — 299
Those character anomalies that express themselves in sexual perver-
sions have naturally been strongly self-destructive during all historical peri-
ods. An entirely peculiar case at present is the case where homosexuals are
enlightened by others of their ilk through extensive recruitment. The
resulting holding back of this type of person from marriage might work
toward a general decrease in psychopathic predispositions.

From Fritz Lenz, Grundriß der menschlichen Erblichkeitslehre und Rassenhygiene, Bd. 2:
Menschliche Auslese und Rassenhygiene (Munich: J. F. Lehmanns Verlag, 1921),
15–20. Translated by Greg Eghigian.

Germany
“The Law for the Prevention
of Hereditarily Ill Offspring”
(14 July 1933)

In January 1933, Adolf Hitler was named chancellor of Germany,

and the Nazi Party entered a governing coalition. Within six
months, Hitler and the party effectively turned the German govern-
ment into a one-party system. With a much firmer hold on power,
the National Socialists moved to address their domestic policy goals.
After first passing a set of laws restricting the rights of German
Jews, the new regime established a law in July calling for the com-
pulsory sterilization of those deemed “hereditarily ill.” With the
law’s taking effect in 1934, authorities moved swiftly. In the first
year alone, eighty thousand were sterilized. All told, estimates are
that around four hundred thousand people were sterilized under
the 1933 law, 75 to 80 percent under the diagnosis of “moral fee-
ble-mindedness.” In contrast to Sweden, where a similar law was
applied almost exclusively to women, the German law was used
against both sexes equally.
300 — Psychiatric Eugenics in Nazi Germany
The Reich government has passed the following law, and hereby announces

§1
(1) Anyone who is hereditarily ill can be sterilized, if, according to the
experience of medical science, it can be expected in all probability that his
[sic] offspring will suffer from severe physical or mental hereditary defects.
(2) Hereditarily ill is, according to this law, anyone suffering from one
of the following illnesses:
congenital feeble-mindedness
schizophrenia
manic depression
hereditary epilepsy
Huntington’s chorea
hereditary blindness
hereditary deafness
severe hereditary physical deformity.
(3) In addition, anyone suffering from severe alcoholism can also be
sterilized.

§2
(1) Authorized to make a request is anyone who should be sterilized.
If this person is legally incompetent or is legally incapacitated because of a
mental weakness or has not yet reached age eighteen, then the legal
guardian is authorized to make the request. He [sic] requires the permis-
sion of the legal guardian court. In all other cases of limited competence,
the application requires the consent of the legal guardian. If an adult has a
professional caretaker, then his [sic] consent is necessary.
(2) A certificate from a licensed physician in Germany is to be attached,
confirming that the individual to be sterilized has been informed about the
nature and consequences of the sterilization.
(3) The application can be rejected.

§3
For inmates of a hospital, psychiatric or nursing facility, the state physi-
cian, or for inmates of a penal facility, the warden, can also apply for steril-
ization.

§4
The application is to sent to the local office of the Hereditary Health
Court in written form or dictated as a statement. A medical examination
 “The Law for the Prevention of Hereditarily Ill Offspring” — 301
report or something similar must lend credibility to the relevant facts in
the application. The local office has to inform the state physician of the
application.

§5
The District Hereditary Health Court that has general jurisdiction over
the individual to be sterilized is responsible for the decision.

§6
(1) The Hereditary Health Court is to be affiliated with a regional
court. It consists of regional court judge as chair, a state physician, and
another physician licensed in Germany who is especially familiar with
eugenics. A deputy is to be appointed for each member.
(2) A chair may not be anyone who has decided over an application for
permission to guardian rights according to §2, Par. 1. If a state physician
has made the application, then he [sic] may not be involved in the decision.

§7
(1) The proceedings of the Hereditary Health Court are not public.
(2) The Hereditary Health Court must carry out the necessary inves-
tigation. The court can examine witnesses and experts as well as order the
personal appearance and medical examination of the individual to be steril-
ized, and in cases of unexcused absences, to demand his [sic] appearance.
Civil court procedure regulations are to be applied as it relates to the exam-
ination and the swearing in of witnessing and experts as well as the exclu-
sion and rejection of court personnel. Physicians who are questioned as
witnesses or experts are obligated to maintain their professionalism in mak-
ing a statement. Court and administrative authorities as well as treatment
facilities must respond to the Hereditary Court’s request for information.

§8
The court must come to its own decision on the basis of the entire
results of the proceedings and the evidence. The decision is reached follow-
ing verbal discussion and requires a majority. The decision is to be written
up and to be signed by all those members participating in its formulation.
It must cite the reasons for which the sterilization has been approved or
rejected. The decision is to be sent to the original applicant, the state physi-
cian, as well as to that person for whom the sterilization was applied, or, in
the case they are not legally capable, to his [sic] legal representative.
302 — Psychiatric Eugenics in Nazi Germany
§9
Persons identified in §8, Sentence 5 can submit a written or dictated
appeal of the decision before the local office of the Hereditary Health Court
within a period of one month after its delivery. The appeal postpones any
decision. The Hereditary Health Court decides on the appeal. If the appeal
deadline is missed, then restitutio in integrum in keeping with the guide-
lines of civil proceedings is permissible.

§ 10
(1) The Superior Hereditary Health Court is affiliated with the
Regional Superior Court and has jurisdiction over the same district. It con-
sists of a member of the Regional Superior Court, a state physician, and a
physician licensed in Germany, who is especially familiar with eugenics. A
deputy is to be appointed for each member. §6, Par. 2 obtains, as appropri-
ate.
(2) Procedures before the Superior Hereditary Court are governed by
§§7, 8.
(3) The decision of the Superior Hereditary Court is final.

§ 11
(1) The necessary surgical procedure for the sterilization may only be
carried out in a treatment facility by a physician licensed in Germany. This
physician may only first undertake the operation, once the order for steril-
ization is finalized. The highest authority in the federal state determines
the treatment facilities and physicians who are authorized to perform the
sterilization. The operation may not be undertaken by the physician who
made the application or served as a member of the committee in the pro-
ceedings.
(2) The physician performing the operation must file a written report
to the state physician about the performance of the sterilization, with infor-
mation about the procedures applied.

§ 12
(1) If the court has made a final decision in favor of sterilization, it is to
be carried out even against the will of the person to be sterilized, as long as
this individual has not filed an appeal. The state physician is to enlist police
authorities to carry out necessary measures. If other measures are not suf-
ficient, then the application of direct force is permitted.
 “The Law for the Prevention of Hereditarily Ill Offspring” — 303
(2) If circumstances exist that demand another examination of the evi-
dence, then the Hereditary Court is to rehear the case, and the sterilization
is to be temporarily postponed. If the application was [originally] rejected,
then a rehearing is only permissible if new facts have emerged that justify
the sterilization.

§ 13
(1) The state carries the costs of the court proceedings.
(2) The costs of the medical operation are covered by the sickness
insurance board to which the person belongs, [or] for those in need, the
welfare association. In all other cases, the costs are covered by the state and
the individual being sterilized, up to the lowest standard rates according to
medical fee regulations and the average standard rates for public treatment
centers.

§ 14
Sterilization that does not follow the regulations of this law as well as
a removal of the gonads are only permissible if a physician carries them out
according to governing practices in medicine, in order to avoid a serious
threat to the life or health of the individual on whom the operation is being
performed and with their consent.

§ 15
(1) Persons taking part in the legal proceedings or in carrying out the
surgical operation are obligated to keep these secret.
(2) Anyone violating confidentiality will be sentenced to prison for up
to one year or given a fine. Prosecution is initiated only on the basis of an
application. The chair can submit the application.

§ 16
(1) The execution of this law is the responsibility of the federal states.
(2) The highest state authorities determine the location and district of
the responsible courts, subject to regulation §6, Par. 1, Sentence 1 and §10,
Par. 1, Sentence 1. They name the members and their deputies.

§ 17
The Reich Minister of Interior, in agreement with the Reich Minister
of Justice, issues the necessary legal and administrative regulation for exe-
cuting this law.
304 — Psychiatric Eugenics in Nazi Germany
§ 18
This law comes into force on 1 January 1934.
The Reich Chancellor Adolf Hitler
The Reich Minister of Interior Frick
The Reich Minister of Justice Dr. Gürtner

From Gesetz zur Verhütung erbkranken Nachwuchses vom 14. Juli 1933,
www.documentarchiv.de. Translated by Greg Eghigian.

Documents on the “T-4” and “14 f 13”

Programs
(1939–1945)

Using the outbreak of World War II as a pretext, Hitler directed his

personal physician, Karl Brandt, in 1939 to initiate a program that
would carry out the medical killing of individuals deemed to be liv-
ing a “life unworthy of life.” Asylum directors, pediatricians, psy-
chiatrists, nurses, and hospital staff were recruited for the
operation, which became known as the T-4 Program. Officially run-
ning from October 1939 until August 1941, the program was
responsible for the killings of around one-third of the institutional-
ized psychiatric population—men, women, and children—by
means of starvation, medication overdose, or gassing. Although the
program was supposed to be clandestine—lies were concocted to
tell relatives about the fate of their loved ones—rumors spread. By
fall 1941, the T-4 Program was formally discontinued. The killings
went on, however, shrouded in more secrecy than ever. In addition,
many T-4 personnel were transferred to eastern Europe, where
their experience was used to run a new SS operation aimed at killing
concentration camp inmates incapable of hard labor or suffering
from incurable diseases—the 14f13 Program. During the years
1939–1945, roughly two hundred thousand people were killed
under the two programs.
 Documents on the “T-4” and “14 f 13” Programs — 305
The following texts give us a glimpse into the thinking and logis-
tics behind the killing operations and what staff and patients knew
about them. The first is a letter by Dr. Irmfried Eberl, the director
of the gassing facilities in Brandenburg and Bernburg, in which he
discusses his views on a draft of a possible euthanasia law (the law
was never enacted). The second is an internal T-4 document that
shows just how informally directives were transmitted to personnel.
The third text represents a report by a former patient at the asylum
in Grafeneck, entered into evidence during the 1949 trial of staff
who had been involved in the T-4 operations there. The final doc-
ument is postwar testimony from Dietrich Allers, the former head
of the Central Euthanasia Office (a German court later found him
to be involved in at least thirty-four thousand deaths).

Position of Dr. Irmfried Eberl on the Draft of a

Planned Euthanasia Law (with Reference to Mercy
Killing and the Elimination of “Life Unworthy of Life”)

6 July 1940
To Reich Committee for the Scientific Registration of Severe
Hereditary and Constitutional Afflictions
Berlin W 9
Post Box 101
Re: Your Letter of 3 July 1940
On the naming of the law, I can say nothing more on the subject, for it
is my opinion that the title “Law on the Killing of Those Incapable of Liv-
ing” would be the most sensible, but it had to be abandoned. The term
“assistance in dying” [Sterbehilfe] is unfamiliar, but it will doubtless gain rel-
evant content through the law itself.
The demarcation of registered cases according to the law is clear in §1.
In §2, under these cases would fall:
a) all schizophrenics, as long as they are capable of no or only mechan-
ical occupational activity;
b) all feeble-minded who are no longer capable of any productive activ-
ity, including within the facility;
c) all syphilitic patients for whom the course of the disease is so
advanced that they are no longer capable of productive work;
306 — Psychiatric Eugenics in Nazi Germany
d) all epileptics who either have frequent seizures or manifest signifi-
cant changes in character;
e) all cases of senile dementia who are considerably unclean and also
require constant commitment in a therapeutic or nursing home facility and,
in their earlier years, made no notable contributions to the benefit of the
people or the nation;
f) in addition, all remaining mental disturbances that are not suited to
productive activity.
Productive activity refers to the fact that the patient in question does
not simply perform mechanical activities, but rather he, for example, in agri-
culture, works with others and is capable of making appropriate contribu-
tions. Patients who, for instance, run around in field details, but there do
nothing or very little, are obviously to be included. Furthermore, all crimi-
nals who require psychiatric institutionalization naturally fall under this
law.
As to the substantive content, I have the following to say:
Re: §2, Par. 2. Here, acquired afflictions that are caused by war injury
or factory accident are to be excluded. I would like to restrict this exception
in sofar as such a patient can be given assistance in dying, if he expressly
wishes it.
Re: §4, Par. 4. Here I would like to broach the question of whether two
years of institutional observation suffices in order to determine that a
chronic mental illness is incurable.
....
The medical community will welcome this law, particularly §1, since
the physician is often in the situation where severely ill, incurable patients
long for death, yet he is not in the position today to provide this help; in
this case, the killing must fall to his own conscience.
It is also the case that the people will absolutely understand and wel-
come §1, apart from the absolutely Catholic-oriented part of the popula-
tion. The impact of the second part of the law will be another matter, i.e.,
the elimination of life unworthy of life. Even if it’s the case that this kind of
law is already in the air to some extent—thus, a part of our people will
understand it—a not insignificant part will offer considerable resistance, in
particular when it come to the family members of the mentally ill. The fur-
ther consequence of this will be that it will become much harder to get the
mentally ill into institutions, as long as they have the slightest possibility of
 Documents on the “T-4” and “14 f 13” Programs — 307
accommodation and care at home. What consequences this can have for
public health and criminality is hard to assess. Nevertheless, I believe that
this law will gain acceptance just as the marriage health law and the law for
the prevention of hereditarily ill offspring themselves have over time and
that, with appropriate enlightenment—which would have to be done at the
same time or, better yet, before its announcement—the law will meet with
appropriate approval. . . .
Heil Hitler!
Eberl

“Removal According to a Strict Standard”: Medical Examination

Report Standards of Bouhler/Brandt—an Internal T-4 Document

Decisions about euthanasia-authorized personnel with regard to medical

examination reporting (taking into account the results of the conversation
at Berchtesgaden on 10 March 1941)*
1. The removal of all those who are incapable of performing productive
work (including in institutions), in other words, not only the mentally
dead.
2. Not to be included are those war veterans who have served on the
front, were wounded, or have received decorations. In evaluating the value
of merits on the front, particularly decorations, Herr Jennerwein makes the
decision.† Questionable upcoming cases that appear in our facilities are to
be returned there until Herr Jennerwein has made a decision on the basis
of the records. Otherwise, war participation does not protect one from
being included in the operation.
3. With seniles, the greatest restraint, only in pressing circumstances,
e.g., criminality or asociality, inclusion. In both of these last cases, records
are to be consulted in each case and copies of excerpts from the documents
are to be attached.

*Editor’s note: Philipp Bouhler was head of the Office of the Chancellery. Karl
Brandt was Hitler’s personal physician. Both men acted as Hitler’s authorized rep-
resentatives in the killing program, taking orders directly from the Führer himself,
often from his retreat in Berchtesgaden.
†
Editor’s note: “Jennerwein” was the pseudonym of Viktor Brack, an engineer
working in Hitler’s chancellery office who later became involved in the construction
of a number of death camps.
308 — Psychiatric Eugenics in Nazi Germany
4. Only German nationals are to be included in the operation, in other
words, no Poles. A concentration of all Poles in purely Polish facilities in
the eastern districts is foreseen. Outside of the Protectorate, institutional-
ized Czechs of German nationality can be included. Czechs of Czech
nationality are supposed to be deported to the Protectorate.
If citizenship cannot be determined, this should be determined by our
authorized personnel, if possible.
In cases where citizenship still cannot be determined, the case should
be rejected until a conclusive conversation with State Secretary Frank.
Enemy foreigners may also not be included in the operation. Of those
who have no citizenship whatsoever, only those for whom it can be proved
they have had no one looking after them for a longer period of time.
5. For the time being, do not work in Alsace, Lorraine, Luxemburg,
Eupen, Malmedy, the Protectorate and [General] Government.
6. Foreign and stateless Jews are to be placed in a Jewish facility built
for them, insofar as deportation to their homeland—thinking here in par-
ticular of Switzerland—is not possible.
For Jews from overseas, a notification is not to take place.
7. The children who fall within the large operation will be medically
examined and reexamined by the national consortium of psychiatric and
nursing care facilities. Those cases that are positively evaluated will be given
over to the national committee for removal.
The children in Bethel should be treated with special care.
Otherwise, just as before, removal according to a strict standard!

“I fear that the Führer’s book Mein Kampf represents the

foundation”: Copy of a Report of the Patient Richard H. (Zwiefalten)

The rumor—that in Grafeneck people were being turned into angels

and the corpses were being burned, so that graves could not be dug, no
cause of death determined—did not come from me. I made the sole mis-
take of speaking openly about what others recount, in the presence of
nurses, to repeat it, in order to give them the possibility of denying the
rumor. This rumor comes from multiple outside sources, I cannot be
made responsible for what is common knowledge in Stuttgart and in
other cities.
Proof.
 Documents on the “T-4” and “14 f 13” Programs — 309
1. A patient who is no longer here told 15 patients, he himself wit-
nessed how two children ages 5 and 6 were given an injection in another
ward, after which they died. So that no examination would be possible, both
were taken to G. and burned. It is clear that I could not say anything, since
all the patients know that I was not on such a ward, but the 15 patients
heard this.
2. Another patient recounted, he himself overheard a staff person ask
another, “What did you see in Grafeneck?” This one answered, “You don’t
see anything of the operations, that’s a lie, you can only see how the smoke
from the cremations rises.” I didn’t tell anyone about it, I did not see any
smoke and didn’t hear any staff people.
3. A visitor (I did not have the visit myself) brought the news that a
teacher by the name of Sch. arrived from Weissenau to Gr. and there dis-
appeared. Family members inquired and finally it was admitted he died
shortly after arrival in G., that is well known in the entire town. I know
nothing about that, I didn’t tell anyone.
4. Many patients say they themselves have seen that the car, when it
arrives empty in order to pick up patients, each time brings 4–5 large bags
full of old clothes and shoes that come from those cremated. I myself have
seen no bag, no clothes, no shoes, I didn’t tell anyone.
5. A patient who shortly returned, but is no longer here, told 15
patients, he met a painter on a transport in the Munich police jail, who 2
years earlier had worked on the paintings from the old monastery in the
facility, and this guy told him, he was now in preventive detention, on his
way to Dachau, because he spoke truthfully about the fact that various
patients in the facility here died an unnatural death, and, so that a cause of
death could not later be determined, corpses were brought to G. and
burned. I didn’t tell anyone about this, I was not on the transport, I have
not been in Munich for 6 years.
6. Many report that transports arrive at G. every week, from Weisse-
nau, Reichenau, Wiesloch, Schussenried, Winnenden, Zwiefalten, etc. [ ]
these transports were kept secret, one can ask the nurses, drivers, etc.
where the others went, but nobody says anything.
7. One patient said, he was sent to G. and was given a stamp on the
shoulder like the others, later the doctor saw this mark and, in the presence
of the patient, scolded the staff person responsible for the stamp, [saying]
he had said this man is to be set free, he does not belong with the others,
310 — Psychiatric Eugenics in Nazi Germany
this one is not supposed to be stamped. After that, the mark was removed
with a strong liquid.
8. Paul R. got a letter that was widely read, R. let lots of others read it,
his wife wrote, “Are you still in Zwiefalten, are you still alive, we hear so
much these days.”
9. A patient said in front of many others that a staff person told him R.
and U. had also been removed.
10. Another patient recounts, Herr Tr. was removed.
11. A patient recounts and repeated that: Two months ago, his mother
visited him, got to know a woman whose was visiting her son here at the
time. Shortly after, his mother wrote this [second] woman, asking when
she was going to Zwiefalten next, and the answer she received was, unfor-
tunately she can no longer visit her son, he left Zwiefalten, [but] she can-
not find out where to, he probably is no longer alive.
12. I fear that the Führer’s book Mein Kampf, that lies here, represents
the foundation for such rumors, for there on page 144 it states, one is sup-
posed to raise many children, but one must also be sure those who are
raised eliminate all mental and physical weakness, in order to prevent
overpopulation, all wishy-washy humanitarianism here is only cowardice,
etc.

Difficulties in Keeping Secrets:

Statement of Dietrich Allers, Manager of T4

On taking on my position [January 1941] with the National Consortium

[of Psychiatric and Nursing Care Facilities], the situation was such that
only the relatives of patients who were subject to euthanasia were informed
about the death. The original facility and the local welfare association look-
ing after the patient were simply told that, with the patient being trans-
ferred to a transitional facility, their responsibilities were over. Questions
involving the whereabouts of the patient were supposed to be answered
with reference to the order of the responsible national defense commissar
and all mail for the patients as well as all other questions directed to the
national consortium.
For everyone who knew about the collaboration of various state
authorities, quasi-governmental agencies as well as economic organiza-
tions, it is clear that considerable confusion arose. The first consequence
 Documents on the “T-4” and “14 f 13” Programs — 311
was naturally that all the national defense commissars were flooded with
questions from relatives and interested service providers. In principle, the
national defense commissars were provided with the transfer orders and
were also informed about the course of the euthanasia measures, but were
naturally not given specific details. Thus, after an initial response, they
sent questions, etc. on to the National Consortium. The welfare agencies
had to know what became of the patients, since they had contested patient
costs and, to some extent, had taken on pensions and other patient bene-
fits. They demanded reimbursement for earlier benefits, partly the per-
sonal effects, partly they wanted to follow up on the reimbursement claims
on behalf of responsible relatives. For many patients, there were insur-
ances of various kinds. The insurance companies appeared and demanded
information, since, in the meantime, the inheritors were making insurance
claims. The finance offices demanded information because the registry
offices that were solely created for the purpose of euthanasia, as a result of
not knowing the regulations, failed to inform the former about the
patient’s demise. In part, inheritance courts popped up with questions
directed at the National Consortium. This was especially the case for what
was called at the time the Ostmark, where surviving family member hear-
ings were required according to Austrian law. Finally, quasi-governmental
agencies, under whose authority patients in state hospitals were institu-
tionalized, needed to be informed. Military draft authorities, who were
also interested in male residents in the facilities, were to be informed. In
different cases, local welfare organizations and municipal welfare authori-
ties were among those asking questions. And finally, there was the notifi-
cation of the health offices. That was important because of existing
marriage laws at the time.
I believe, with this, I have detailed what kind of work I had before me.
If you imagine that the euthanasia program ran for more than a year, you
can get a sense of the extent of my activities.

From Ernst Klee, ed., Dokumente zur “Euthanasie” (Frankfurt: Fischer Taschenbuch
Verlag, 1985), documents no. 25 (pp. 87–91), no. 32 (pp. 100–103), no. 41 (pp.
112–114), no. 55 (pp. 140–141). © 1985 Fischer Taschenbuch Verlag GmbH,
Frankfurt am Main. Translated by Greg Eghigian.
 Mental Illness,
Psychiatry, and
Communism

Thea H.
(b. 1923)

An Experience of Psychosis
in Post–World War II Germany
(1949)

The experience of hallucination (perceiving someone or something

that is really not there) has long been recognized in Western soci-
ety as a characteristic feature of mental disorder. While ethno-
psychiatrists and historians have noted some striking similarities in
the form that hallucinations have assumed over history, it is also
clear that the content of psychotic experiences differs across soci-
eties and time periods. The following is an excerpt from a letter
written by a German woman, Thea H. (her name has been changed
to protect her identity), to her doctors in the spring of 1949,
shortly after she was checked into the psychiatric clinic at the Char-
ité Hospital in East Berlin. It offers us a unique glimpse into the
mind of a person still actively hallucinating.
Thea H.’s case is particularly instructive in that it takes place
against the backdrop of the end of World War II. Following the
war, both Germany and the city of Berlin were divided into zones
of military occupation (American, British, French, and Russian).
Thea H. was a student living in West Berlin at this time. Hospital
records indicate that she was a devout communist, a fact that appar-

312
 Psychosis in Post–World War II Germany — 313
ently led to her being arrested by the Nazis and held in a concen-
tration camp during the years 1943–1945. Over the course of the
four years following her release from the camp, she found herself in
and out of psychiatric institutions, including the facility at
Haldensleben, under the direction of Dr. Ziegelrot. There, doctors
may well have administered electroshock to her, this being a com-
mon form of treatment for schizophrenia at the time.

28 May 1949

So, you want to know everything—from the point of the events, so to

speak, up to this present moment when my powers have left me? I will now
try again to make visible the order of events and all those powers that affect
being and consciousness—external events, perception, thoughts into
words—will words be enough to convey an alien consciousness? I don’t
know, but I will nevertheless demonstrate my good intentions.
It was already there in those days and in those thoughts that circled
around in my head. Its central point was that paper about transportation,
its statistics, and the question about to what extent it served as a mirror
image of economic development. Economic development—how varied are
its factors and how pathetic, by contrast, are the indicators of transporta-
tion statistics. I had rummaged around, combined, rejected and could not
recognize the standard picture of simple production numbers in correlation
with the track lengths and shipping. The organic structure of capitalism
appeared to me much more significant. It must provide the basis for the
connection of the real relationships between the transportation process and
the normal production processes.
On this question of a mistaken assessment of the matter of organic
structure, I went to Lenin and Stalin for advice. Suddenly the wonderful
conceptual formulation of the organic structure fell into place. . . . After
having finished the reassessment and formulation of the basic thinking of
my essay in my paper “Costs and Prices,” which hardly struck me in the
end as my own product, I chatted with Stalin about the question of the
dialectic in connection with the immortality of the human soul. I explained
to him that I could not believe in the immortality of the soul on the basis
of the theory of dialectics alone. . . . Dialectical materialism teaches that the
314 — Mental Illness, Psychiatry, and Communism
highest form of living material is the brain as the organ of consciousness. If
this highest form of living material dies as a consequence of the death of the
human body and, in its wake, the brain is transformed into its inorganic
parts, then a qualitative change must result that we cannot yet pursue in
reality, in the sense of the Leninist approach to human knowledge.
Stalin replied to this: “My dear child, naturally you are right, for those
invisible unities of consciousness are just the very things that are at the dis-
posal of our active and developing consciousness in order to point out those
processes of the past that still have an effect in the present.”
. . . In the course of the argument I was having, a terrible doubt about
the adequacy of my capacity for judgment now overcame me. I raised a
great many objections against the right to influence my thought in this
unreal form, such that by the end, it was no longer clear to me what
remained of my own mental properties. With that, I was once again with
Stalin. “But my little child,” he grinned at me, “we are simply giving you
[questions], in association with your inner complex of questions that have
emerged out of the confrontation with the world around us—these are rel-
evant preconditions for your further development, for as everyone knows,
questions emerge wherever in real life a solution is needed. As an intellec-
tual worker—something you want to become—you will solve these ques-
tions to a certain extent as part of your training. And how this looks within
the scope of the constantly working collective consciousness, we will show
you one day. First, you will get to know your own capabilities; second, we
will get to know you, something even more important; and third, you will
learn how you have to work as a part of the intellectual collective produc-
tion process, as soon as it becomes a question of peace and the future exis-
tence of this world.” With these words, he looked at me sadly, smiled, and
disappeared.
In his place appeared Prof. Ziegelrot, who once posed the question to
me in [the psychiatric facility at] Haldensleben, “And do you really know
whether you were schizophrenic?” This time he said very seriously and
measured, “You don’t believe that we exist, we who are speaking with you.
We will prove it to you. And since this question so desperately interests
you, you will do what we recommend. You are now a part of a scientific
experiment intended to answer the question, ‘What is schizophrenia?’”
Since I still did not know whether everything was merely an apparition or
reality, I submitted to this instruction, but decided in the meantime to not
 Psychosis in Post–World War II Germany — 315
accept it as reality and made notes in my gray notebook about the instruc-
tions of the collective. These notes, in which I acted as an experimental
subject for an experiment in suggestion, . . . had to have something to say
about the question posed at the beginning. Over the course of the night,
however, the experiment took a strange turn. I was told there is not only
organic, living material on the earth, but also that this material is subject to
laws of development that extend beyond the earth. Organic life has the
function of setting off a process on this earth that has long since taken place
on other stars. We now had to carry this out on our star using atom split-
ting. I despairingly challenged this line of thinking. “You have to ask all
human beings before I perform such an insane act.” I wrung my hands.
Like a pale death’s head, it grinned at me. “But you are located at such
a low level of intellectual development, that you can’t conceive it,” was the
reply.
“But no,” I retorted, “every human being comprehends life, some more
instinctively, others more unconsciously. The present action is determined
by two different spheres. . . . For every human being, [these spheres] can
be developed in a harmonious, interconnected fashion.”
The skulls widened their grins: “No,” said one of them, “we suspect
that in your head is located the highest level of processed subconscious.
[And since] we know your family, we want to observe your consciousness
level while you sleep. Very slowly, we will force you to fall asleep, so that we
can eavesdrop. Your consciousness level is the final life process on earth that
remains unknown to us. But we want this other world, of which we know
nothing, and for this, we must destroy this world of human maggots.”
That was too much for my heart, which was full of joie de vivre and
kindness. I decided to refuse to go along. . . . Dead eyes watched me and
waited for my murderous sleep. I followed the hand of the clock till about
8 a.m. and trembled with my notebook in hand as my sole piece of evidence
of this criminal experiment. I then quickly dressed. Where should I now
go? I packed up my work from the past few weeks in my bag and left the
house. In the thaw of the morning, I marched the streets, not knowing my
goal, finally ending up at my friend’s.
. . . . .I finally sought out a doctor I trusted, Dr. Erdmann, and told him
of my dilemma. There, suddenly, as I tried to explain to him the events of
the past few days, it hit me like a hammer, the knowledge of clarity rejoiced
in me. Two powers have been wrestling in the world, and now, at this
316 — Mental Illness, Psychiatry, and Communism
moment, contact was established. Your inner wrestling is only a reflex of
outward reality. . . .
Once again on the streets, I didn’t know the way I should go. Slowly I
turned in the direction of the zone border Berlin-Brandenburg. Suddenly a
harsh voice said, “We know that this world must be destroyed. Destroyed
will be the world of suffering, of hate, of death, of dearth, and in its place
will be built a world of life and joy.” And then softer, “Do you believe that?”
Sad and exhausted after a sleepless night, I sank to the ground and looked
at the radiant evening sky. “I can’t believe what I don’t know,” I answered.
“Don’t you see that I am a German? For us, death was cloaked as life, and
belief murdered loved ones. I can no longer believe.” Suddenly, Einstein
shook his gray head, looked around, and spoke to an assembly of learned
men: “We have to teach her to believe.” And then he looked me in the eye
just like the evening sky had radiated earlier. “Lay your two hands
together,” he spoke in a friendly way, “and tell us in whom you believe. You
are to receive a treasure from us and to bring it to those in whom you have
faith, so that the world can live in peace.” “Ach,” I lamented, “it’s not so
much faith, but I have always had the experience in my life that they have
been right, and I have constantly felt safe in their hands. I know I could be
wrong, but I believe in the Russians.” These words provoked a peal of laugh-
ter, and it was as if the leaves of the trees shook in the dying evening wind.
“But, little thing,” Einstein finally uttered, “then you are a Bolshevik,
and you belong in the Russian zone. Now see to it that the CIC [American
counterintelligence] does not get you! But as a sign that you may believe in
us, we are giving you something that you are to carry over. It is a power. It
can destroy or create. You trust in the people and in the SED [the East Ger-
man Communist Party]. Now go there, and when you arrive at the [Com-
munist] party school with the gift we now give you, then you and your faith
have won, then you have convinced us. And so that you know, we are the
collective consciences of the world.” And with these words, I sensed some-
thing heavy in my hands and could not pry them apart. As I now crossed
the border, my limbs were heavy and I sensed how the weight of the power
in my hands changed. “Slowly,” a voice warned me, “in your hands, you
hold the contact. If it tears, then the unity of the world is destroyed. You
must protect it.”
I informed the border police jubilantly that the unity of the world had
been prepared. . . . The policemen led me into a house, which I believed was
 Records in the Case of Pyotr Grigorenko — 317
the party school. On the walls hung Karl Marx and a motto “Freedom Is
Insight into Necessity.” They then called the Karl-Marx-School. As they all
grouped around me and then more came, I started trusting. And then one
of them spoke in a quiet voice: “You have reached your goal. Pry your hands
apart.” I believed him and did what I was directed. I then determined, how-
ever, that this was only the police, and that made me sad. They then led me
back to the zone border. Everything was still as it had been. Beams stared
over the street, and I was told to make my way home in the Ami [Ameri-
can] sector. I traveled a bit in a car that happened to pass by. I found every-
thing so gloomy and dead, as if it was the night before the end of the world.
But upon the first rays of the rising sun, I staggered back across the zone
border into the Russian zone, to my friend’s, until I fell exhausted at her
feet.
This then was schizophrenia—atomic physics felt in one’s own body?
My friend brought me here in this madhouse, and here I live until today
and ask myself: “How can a human being live in a world with a divided world-
consciousness without herself suffering from a split consciousness???”

From Bundesarchiv Berlin DQ1/5571. Translated by Greg Eghigian.

Records in the Case of

Pyotr Grigorenko
(1969–1970)

Pyotr Grigorenko (1907–1987) was a decorated major general in

the Soviet Red Army, who, by the 1960s, came to believe that the
USSR was no longer living up to its ideals. Grigorenko became
involved in founding a dissident organization and distributing fliers
calling for more democratic governance. Arrested in 1964, he was
sent to the Serbsky Institute for Forensic Psychiatry in Moscow for
psychiatric evaluation. Clinicians there determined that his
reformist views reflected “a paranoid personality development with
delusions,” and he was committed to a psychiatric institution. He
318 — Mental Illness, Psychiatry, and Communism
was soon released, but over the following four years he continued
speaking out on human rights issues. Arrested again, he was exam-
ined by a psychiatrist, who declared him sane. Unsatisfied, the KGB
sent him one more time to the Serbsky Institute for an evaluation,
which took place in November 1969. The experts at the institute
once again declared him insane, and Grigorenko was committed to
a psychiatric facility for the following several years. In 1991, four
years after his death, a special Russian panel of psychiatric experts
reexamined the files in Grigorenko’s case and declared him to have
been clinically sane.
Grigorenko’s was only the most famous of numerous cases in
which sane Soviet political dissidents were committed to psychiatric
facilities beginning in the early 1960s. Studies conducted after the
fall of the USSR indicate that the practice involved party and state
officials, hospitals, and psychiatrists. One conservative estimate is
that between 1960 and 1985 around 300–675 dissidents were
being held in Soviet psychiatric institutions at any given time.

Grigorenko’s Account of His Psychiatric Examination

at the Serbsky Institute, Written Immediately after the Examination
by the Committee of Experts, in the Period 20–25 November 1969

There is a large room, solidly crammed with office desks. One of these is in
the middle of the room, with four persons seated at it. In the chairman’s
place is a fairly young-looking, plump man with brown, slightly curly hair.
I learned afterwards that this was the director of the Serbsky Institute and
an associate member of the U.S.S.R. Academy of Medical Sciences, Moro-
zov. To his left is Lunts and on his right in a brown suit, the only one not
wearing a white coat. Maiay Mikhailovna sits opposite the chairman. They
show me a place across from the desk, near the chairman. I sit down, I look
around.
“Do you see many acquaintances?” I am asked.
“Yes, but of my old acquaintances there is only Daniel Romanych and
the doctor who sits over there by the window. I met him in Leningrad in
1964 when the question of my discharge from the Lenin Special Psychiatric
Hospital was decided. The others,” I say pointing to the doctors of the
fourth section, “are current acquaintances.”
 Records in the Case of Pyotr Grigorenko — 319
I realize that the commission is at the central desk, the others present
being students. They are settled at desks placed by the wall. . . . Please note
that Lunts is the only one whom I call by his family name: this is a peculi-
arity of the system. According to the law they are obliged to give me the full
names of everyone on the commission, and I even have the right to reject
some and solicit for the inclusion of others. That is how it was in Tashkent,
but here we have high priests who act with pomp and ceremony, and I,
worthless being that I am, do not even have the right to know who they are.
But let us return to the commission. The chairman begins the discussion:
“Well, how do you feel?”
“I do not know how to answer you. Probably like a guinea pig would
feel if he were able to realize his situation.”
“I am not talking about that. I would like to know if you feel differently
from how you did at the session here in 1964.”
“Yes.”
“How?”
“You see, at that time such a method of investigation, transforming a
defendant into a madman, was something for which I was completely
unprepared. I was literally shocked by this discovery and looked upon the
staff at this place as specially selected, hardened criminals. I believed that I
had been brought here to ‘give official sanction’ to my confinement in an
insane asylum for the rest of my days. Therefore, I despised all the employ-
ees and was extremely overwrought and irritable. I did not want to follow
any of the rules and gave much time to the political enlightenment of the
psychiatric experts. All this obviously made a terrible impression on those
around me and might have given some sort of grounds for pronouncing me
insane.”
“As Daniel Romanovich told me, you said to him in a conversation that
what had happened then seemed as though it was happening in a fog.”
“I say the same thing now. My discovery was such a great shock that I
still regard what happened then as a terrible nightmare.”
“And now.”
“Now my position is different. First of all, the examination by a com-
mission of experts was no surprise for me. Secondly, I have known many
very decent psychiatrists, and I have tried to remember, even when dealing
with a criminal institution, that among the people who work there might
be some completely honest individuals. So I have decided in all my personal
320 — Mental Illness, Psychiatry, and Communism
contacts to concentrate my attention precisely on those decent ones. Now
I am completely calm and see around me, not simply doctors, but people. I
hope that the experts will try to see me as a human being too.” (I smiled at
him.)
“Yes, but all you say is related to the events of the examination itself,
whereas there were actions which even without the doctors, raised doubts
about your sanity.”
“I do not know of any such actions.”
“But here in the record of the proceedings of the commission which
determined the possibility of ceasing your confinement in the Leningrad
Special Psychiatric Hospital, it is stated that you admitted that your actions
were wrong.”
“And I admit it now.”
“How can you co-ordinate your two statements?”
“It is very simple. Not every mistake a person makes is the result of a
disturbed mind. My mistakes were caused by my incorrect political devel-
opment—I was too much of a rugged, straightforward Bolshevik-Leninist
by education. I had become accustomed to thinking that only what Lenin
taught is correct. Therefore, when I came up against the discrepancy
between what Lenin wrote and how it was in real life, I saw only one way
out: back to Lenin. But this was a mistake. Irreversible changes have taken
place in our life and no one can turn life back to 1924, or even to 1953. Fur-
ther accomplishments can be achieved only by starting from the present
day, using Lenin’s theoretical heritage creatively, and taking into account all
past experience. When I acknowledge the error of my actions, I was think-
ing above all of this lack of understanding. I did not reveal this then because
they did not require this from me. Therefore, the fact that my mistakes had
nothing to do with those being corrected by psychiatric interference
remained unexplained.”
“How do you explain the fact that after psychiatric intervention you
acted normally for a year and a half and then went back to your old ways?”
“The psychiatrists had nothing to do with my so-called ‘normal’ behav-
ior. I presume you are referring to the fact that I wrote nothing for distri-
bution.” (The chairman nodded affirmatively.) “I wrote nothing in 1965
and 1966 for two reasons, which were beyond my own or the psychiatrists’
control. The first reason was there was no time. I worked as a loader in two
stores in order to earn a living for myself and my family. I earned 132
 Records in the Case of Pyotr Grigorenko — 321
roubles in total, which is almost as much as I paid income tax for my salary
at the Military Academy. The work was very hard. The working day was
twelve hours and there was no day off. I was exhausted when I got home
and had only enough strength to get into bed. I lost so much weight that
my clothes hung on me as they would on a hanger. The second reason for
my silence is that during this first year and a half I still hoped that they
would restore my hard-earned pension, which had been unlawfully taken
away from me. If this had happened, I would not be talking to you now.
While I was in the Leningrad Hospital I had already planned that I would
write a history of the Great Patriotic War [World War II] when I was
released. My heart was set on this work. But experience showed that illegal
repressions do not cease, but instead piled up with time. The fact that I was
barred from any kind of work, which forced me and my family to live in a
state of semi-starvation, together with the never-ending insolent and illegal
shadowing, demonstrated graphically that the time had not yet come for me
to climb into an ivory tower and pursue ‘pure science.’ As long as our coun-
try is not provided with a reliable shield against tyranny it is the duty of
every honest man to participate in creating this shield, whatever the threats
to him. But you are mistaken when you say that I went back to my old
ways. What I have done in the past two years does not even superficially
resemble my old ways.” . . .
“Do you definitely want to be brought to trial?”
“Unfortunately it is not up to me to decide this question. Of course, I
would prefer to have the case discontinued at the preliminary investigation
stage. But, I repeat, this does not depend on me.”
“But treatment could save you from being brought to trial.”
“There is nothing for me to be treated for, and I have no intention of
feigning illness in order to be spared responsibility. I am prepared to answer
fully for my actions.”
“But if they convict you, you will lose your pension.”
“There is a good Russian proverb: ‘If they cut off your head, you don’t
cry over your hair.’ Whether I am convicted or put in a prison called a spe-
cial psychiatric hospital, I have still lost my freedom. And a pension cannot
take the place of freedom. Why should I grieve over my pension? Why
assume I will be convicted without fail? I do not consider myself guilty and
I will try to prove this to the court.”
“So you plan to defend yourself regardless of everything?”
322 — Mental Illness, Psychiatry, and Communism
“I do not quite understand what you mean by ‘regardless of every-
thing.’ I do not plan to lie or shift. I will speak about my activities frankly
and honestly and give my motives for them. All in all, I will face the truth
as I see it. But even if I do not succeed in proving my innocence, the maxi-
mum sentence I could get, according to the article under which I am
charged, is three years. This means that by the time the sentence takes
effect I will have about two years left to serve. A so-called cure would take
no less time. Moreover, I would not spend these two years in a closed
prison, but in a labor camp, where I would work in fresh air among normal
people. Furthermore, they could give me less than three years, or even
exile—there are precedents for this—in which case I would not lose my
pension. Finally, there is always the possibility of an amnesty on the occa-
sion of Lenin’s birth centenary. If I am convicted this amnesty could apply
to me. If I receive ‘treatment,’ the possibility is excluded. They don’t give a
madman amnesty from his illness.”
With that my second forensic psychiatric examination for the year
and my second encounter with the Serbsky Institute came to an end. I
still do not know the results of the Serbsky commission. When I find out
it will finally be clear to me whether this Institute is merely a criminal
establishment left over from the accursed past or if the people there are
also foul criminals, dangerous to society, who hide themselves behind
white coats.

Report No. 59/S on the In-Patient Forensic

Psychiatric Examination of P. G. Grigorenko

On 19 November 1969 in the Serbsky Central Scientific Research Institute

of Forensic Psychiatry, an examination was made of P. G. Grigorenko, born
in 1907, and charged under Article 190–1 of the Russian Criminal Code.
Grigorenko entered the Institute in compliance with an order of 13 Octo-
ber 1969 from the Investigator of Especially Important Cases of the Uzbeck
Procuracy in connection with doubts about the psychological soundness of
the patient.
From statements by the patient, medical records and documents of the
case, it is known that he lost his mother at an early age, grew up in difficult
material circumstances and began to do heavy physical labor while staying
quite young. He was a weak unhealthy child. He began school at the age of
 Records in the Case of Pyotr Grigorenko — 323
eight. In character he was lively, sociable, inquisitive, easily carried away
and candid. He always stood up for his own opinions and defended the
weak. He was a good student After completing the fourth form, he went to
work as a metal worker’s apprentice. From this time onwards he took an
active part in public life and entered the Komsomol [a Soviet youth organ-
ization]. He studied at the Workers’ Faculty of the Kharkov Technological
Institute. In 1931 he was enlisted in the army and sent to the Military Engi-
neering Academy. . . .
He later graduated from the General Staff Academy and served in Khar-
barovsk until 1943. He worked, in his own words, with enthusiasm and
tried to investigate every matter thoroughly, always looking for what, in his
opinion, had significance for the solution of the given problem.
In the early years of the war he received a Party reprimand for critical
remarks about the state of the Soviet armed forces. From 1943, he took part
in the Patriotic War. In 1944, he was wounded in the leg and suffered a
contusion with brief loss of consciousness. He was not hospitalized.
After the war he was employed at the Frunze Military Academy as a
senior instructor, and in 1949 defended his master’s thesis. . . . In 1959, he
was appointed head of the Faculty of Military Administration. At this time
he had no complaints about his health, was active, conducted scientific
work, published articles, and followed the social and political events in the
country. He pondered a great deal over the occurrences at the twentieth
Party Congress and came to the conclusion that the consequences of the
“personality cult” had not yet been eliminated completely and that there
were still “Bonapartist methods of work” in the Party.
In 1961, he expressed “critical remarks” at a district Party conference
and was afterwards dismissed from his post. He took this very hard, was
convinced of his innocence and tried to restore his rights. At this time, he
suffered headaches, noises in the head, and pains in his heart. He became
more quick-tempered and irritable and could not stand contradiction. In
1962, Grigorenko was assigned to the post of chief of the Operations
Department of the army in the Maritime Territory.
As is evident from Report No. 25/S of the forensic psychiatric exami-
nation in 1964, which contains information about his period of service in
the Maritime Territory, Grigorenko, in addition to being energetic and
exceptionally industrious, suffered from conceit; overestimated his knowl-
edge and capabilities, was quick-tempered, unrestrained, and did not have
324 — Mental Illness, Psychiatry, and Communism
authority. He says that he was offended by his transfer from Moscow and
thought that they had deliberately “sent him away.” He then concluded
that the government was “decaying” and had departed from Leninist norms
and principles. He thought it was essential to conduct a campaign of
instruction and explanation among the people aimed at “destroying” the
existing order. While studying Marx and Lenin, he had thought a great deal
about the mistakes of the leadership and tried to outline the correct course.
He was engrossed in these thoughts and considered that for him this was
a “matter of conscience and honor.”
In 1964, while on leave in Moscow, he distributed leaflets containing
these views. Criminal charges were brought against him under Article 70,
paragraph 1, of the Russian Criminal Code. He underwent an inpatient
forensic psychiatric examination at the Serbsky Institute from 12 March to
18 April 1964.
His psychological condition was described as manifesting reformist
ideas, in particular that of the reorganization of the state apparatus com-
bined with an overestimation of his personality reaching messianic propor-
tions. He was emotionally caught up in his own experiences and was
unshakeably convinced of the rightness of his actions. In addition, elements
of pathological reactions to his surroundings were noted, as well as
unhealthy suspiciousness and a sharply expressed emotional excitability.
The conclusion of the team of experts of 17 April 1964 was that: “Gri-
gorenko suffers from a mental illness in the form of a paranoid (delirious)
development of his personality, accompanied by early signs of cerebral arte-
rio-sclerosis. He is not of sound mind and needs compulsory treatment in
a special psychiatric hospital.”
Grigorenko underwent compulsory treatment at the special psychiatric
hospital in Leningrad until 22 April 1965. While in the hospital he at first
behaved with self-confidence and was obstinate and persistent in his
demands. He was easily irritated and then became malicious and irate, and
dwelt on emotionally colored experiences. He exhibited a tendency to inter-
pret facts broadly and to overestimate his own capabilities. He did not look
critically at his own condition and at the situation that had developed. Sub-
sequently, he became calmer and his behavior seemed more normal. . . .
On 16 March 1965, the commission reached the conclusion that Gri-
gorenko had been suffering from mental illness in the form of a paranoid
development of the personality with an early cerebral arterio-sclerosis. At
 Records in the Case of Pyotr Grigorenko — 325
that time, however, Grigorenko had recovered from this illness and was in
a state of steady equilibrium which did not require hospital treatment. He
only showed signs of cerebral scleroris.
After his discharge from the hospital, as the patient tells it, he learnt
that he had been deprived of his rank and pension. He took this very hard,
and thought that he had been treated unjustly and “inhumanely.” He wrote
letters and statements, but did not achieve anything. He found himself in
difficult material circumstances because, having being classified as an
invalid of the second category, he could not find work. . . .
In 1965, after sending a series of letters and statements to various
departments, he was allotted a pension of 120 roubles. However, he did not
consider the decision fair and continued to send letters and applications
requesting a review of the decision. But he received no answer. As he notes,
this made him take offense and become irritable. . . .
Around 1967, he began to engage himself once more in “general polit-
ical” questions and to direct all his energy toward the struggle for truth. He
quickly became acquainted with people whose views were acceptable to
him, readily consorted with them and worked on articles in which he set
forth his views on various events taking place within the country. At the
same time, he wrote letters to government leaders openly criticizing their
activities and expressing his own opinions. He was enthusiastic about this
work and considered it useful and necessary; it gave him an escape from the
inactivity, which he believed, the KGB was trying force upon him. Though
his character continued to be lively and active, he became even more hot-
tempered and emotionally vulnerable. He considered it necessary to
respond to any events which he thought were unjust, even though they had
no relation to him. It was by precisely these strivings that he explains his
activity during the trials of certain person charged under Articles 70 and
190–1 of the Russian Criminal Code and the active help he gave the
Crimean Tatars who were trying to return to the Crimea . . .
On 18 August 1969, Grigorenko underwent an outpatient forensic
psychiatric examination under the chairmanship of Professor F. F. Deten-
gof in Tashkent. The commission did not discover any psychopathological
disorders and reached the conclusion that Grigorenko showed no symp-
toms of mental illness, just as he had shown no such symptoms during the
time when he committed the incriminating offense (1965–69). They con-
cluded that he is of sound mind.
326 — Mental Illness, Psychiatry, and Communism
In the documents of his criminal case there is testimony from wit-
nesses, including his relatives, in which Grigorenko is described as honest,
with high principles, well-balanced and affable, and no strangeness in his
behavior is noted. At the same time, other witnesses testified that he had
“dictatorial ways,” talked much and heatedly, and when he was arguing his
point of view, tried to force it upon the person with whom he was convers-
ing. Witnesses who saw Grigorenko outside the courthouse on 9–11
October 1968, during the trial of persons indicted under Article 190–1 of
the Russian Criminal Code, observe that he “stood out” by his conduct,
that he was active, expressed his view on the trial loudly and used abusive
language, insulting the druzhinniki (voluntary militia) by calling them fas-
cists and members of the Black Hundred [a far-right monarchist move-
ment]. He drew a crowd of people around him, told them about himself and
shouted that he would fight for democracy and truth. During the period of
investigation, as the documents in his case show, Grigorenko would shout
in answer to reproofs and insult the prison staff when he took exercise or
was in his cell. He was agitated during the interrogation and for a time
refused to eat.
The examination at the Institute has revealed the following:
Neurological Condition: Right pupil is larger than the left, mesolabila
skin creases symmetrical. Tongue deflects slightly to the left when thrust
out. Lumbar lordosis flattened, flexibility of the spine in the neck and lum-
bar regions somewhat limited. Reflex of right knee is less than with his left
knee, slight positive Marinesko symptom on both sides. All types of sensa-
tion are normal. Steadiness in Romberg position. Wasserman reaction in
the blood is negative. An examination of the optic fundi shows traces of a
partial disturbance in the circulation in the upper branch of the central vein
in the right eye.
The electro-encephalographic examination showed: disruptions of
the bio-electrical activity of a diffusive character and a persistent asym-
metrical amplitude by means of the presence of synchronic flashes of alpha-
oscillations and pathological forms of activity, more clearly on the left, and
a lowering lability of the brain structure. Accent of changes in the left cere-
bral hemisphere.
Psychological Condition: Upon his arrival and during the first days of his
stay at the Institute, the patient protested against the forensic psychiatric
examination. He was agitated, spoke in loud tones and asserted that his
 Records in the Case of Pyotr Grigorenko — 327
placement in the Institute for an examination was “tyranny,” all the more
so since the previous outpatient commission had pronounced him psycho-
logically healthy. Subsequently the patient became calmer and readily made
contact with the doctor. During the conversations he behaved with self-
respect and willingly gave information about himself, but then would dwell
on an emotional experience and begin to raise his voice. His face would turn
red, his hands would begin to shake and he would get into a state of emo-
tional agitation. . . .
He views his struggle as absolutely legitimate and the path which he
has followed as the only correct one. When attempts were made to dis-
suade him he became angry and malicious, and declared to the doctor that
his entire life has been a struggle, that he foresaw the possibility of arrest
but this has never stopped him since he cannot repudiate his ideas. At pres-
ent he considers himself mentally healthy.
He formally declared in a conversation with doctors that he does not
rank himself among prominent people and claims that he does not think his
activity has historical significance. He said that he acted according to the
dictates of his own conscience and hopes that his struggle will have some
effect.
His letters, which are among the documents of the case, reveal a bla-
tant overestimation of the importance of his activity and of the significance
of his personality, as well as reformist ideas, which he is unshakeably con-
vinced are right. He also manifests a distinct tendency to write numerous
long letters. These show that, although his critical faculty is disturbed, he
has preserved his previous knowledge and skills, as well as his former abil-
ity to present formally a consistent account of the facts. In his section of the
Institute the patient tries to remain calm, is polite and sociable with those
around him and reads literary works.

conclusions
Grigorenko is suffering from a mental illness in the form of a pathological
(paranoid) development of the personality with the presence of reformist
ideas which have arisen in his personality, together with psychopathic char-
acter traits and the first signs of cerebral arterio-sclerosis.
This is corroborated by his psychopathic state in 1964, which arose
during an unfavorable situation and expressed itself in highly emotional
ideas of reformism and persecution. Later, as is evident from documents in
328 — Mental Illness, Psychiatry, and Communism
his criminal case and data from the present clinical examination, he did not
fully recover from his paranoid condition. Reformist ideas have become per-
sistent and determine the patient’s behavior. Moreover, the intensity of
these ideas increased periodically as a result of various external circum-
stances which have no direct relation to him. This is accompanied by an
uncritical attitude towards his own statement and actions. This mental ill-
ness excludes the possibility of the patient being responsible for his actions
or having any control over them; hence, the patient must be pronounced of
unsound mind.
The commission cannot agree with the diagnosis of the outpatient
forensic psychiatric examination conducted in Tashkent because of the
presence of pathological changes in Grigorenko’s psyche which have been
set forth in this report. These changes could not be revealed in the course
of an outpatient examination since the patient’s behavior is outwardly nor-
mal, his statements are formally consistent, and he has preserved his for-
mer knowledge and skills—all of which is characteristic of a pathological
development of the personality. Grigorenko requires compulsory treatment
for his psychological condition in a special psychiatric hospital, since the
paranoid ideas of reformism described above are of a persistent nature and
determine the patient’s behaviour.
Signed by Corresponding Member of the U.S.S.R. Academy of Medical
Sciences, G. V. Morozov; Corresponding Member of the U.S.S.R. Academy
of Medical Sciences, Professor V. M. Morozov; Professor D. R. Lunts;
Senior Research Officer Z. G. Turova; Lecturer and Junior Research Offi-
cer M. M. Maltseva

From P. G. Grigorenko, The Grigorenko Papers: Writings by General P. G. Grigorenko

and Documents on His Case (Boulder, CO: Westview, 1976), 145–165. Copyright
Andrew Grigorenko. With kind permission from Andrew Grigorenko.
 “Declaration of Hawaii” — 329

World Psychiatric Association

“Declaration of Hawaii”
(1977)

The political abuse of psychiatry in the Soviet Union first began to

be widely publicized in the Western media in the 1970s. At the
Fifth World Congress of the World Psychiatric Association (WPA)
in 1971, critics demanded an end to the practice of institutionaliz-
ing dissidents in psychiatric facilities. It was not until the Sixth
World Congress of the WPA in Hawaii in 1977, however, that the
organization publicly condemned the USSR. In addition, the Con-
gress unanimously adopted a code of ethics known as the Declara-
tion of Hawaii. The declaration was subsequently updated at the
1983 Congress in Vienna, and in 1996, the WPA General Assem-
bly in Madrid approved a comprehensive statement of psychiatric
ethical guidelines.

Ever since the dawn of culture ethics has been an essential part of the heal-
ing art. Conflicting loyalties for physicians in contemporary society, the del-
icate nature of the therapist-patient relationship, and the possibility of
abuses of psychiatric concepts, knowledge, and technology in actions con-
trary to the laws of humanity all make high ethical standards more neces-
sary than ever for those practicing the art and science of psychiatry.
As a practitioner of medicine and a member of society, the psychiatrist
has to consider the ethical implications specific to psychiatry as well as the
ethical demands on all physicians and the societal duties of every man and
woman.
A keen conscience and personal judgment is essential for ethical behav-
iour. Nevertheless, to clarify the profession’s ethical implications and to
guide individual psychiatrists and help form their consciences, written rules
are needed.
Therefore, the General Assembly of the World Psychiatric Association
has laid down the following ethical guidelines for psychiatrists all over the
world.
330 — Mental Illness, Psychiatry, and Communism
(1) The aim of psychiatry is to promote health and personal autonomy
and growth. To the best of his or her ability, consistent with accepted sci-
entific and ethical principles, the psychiatrist shall serve the best interests
of the patient and be also concerned for the common good and a just allo-
cation of health resources.
To fulfill these aims requires continuous research and continual educa-
tion of health care personnel, patients, and the public.
(2) Every patient must be offered the best therapy available and be
treated with the solicitude and respect due to the dignity of all human
beings and to their autonomy over their own lives and health.
The psychiatrist is responsible for treatment given by the staff mem-
bers and owes them qualified supervision and education. Whenever there
is a need, or whenever a reasonable request is forthcoming from the patient,
the psychiatrist should seek the help or the opinion of a more experienced
colleague.
(3) A therapeutic relationship between patient and psychiatrist is
founded on mutual agreement. It requires trust, confidentiality, openness,
co-operation, and mutual responsibility. Such a relationship may not be
possible to establish with some severely ill patients. In that case, as in the
treatment of children, contact should be established with a person close to
the patient and acceptable to him or her.
If and when a relationship is established for purposes other than ther-
apeutic, such as in forensic psychiatry, its nature must be thoroughly
explained to the person concerned.
(4) The psychiatrist should inform the patient of the nature of the con-
dition, of the proposed diagnostic and therapeutic procedures, including
possible alternatives, and of the prognosis. This information must be
offered in a considerate way and the patient be given the opportunity to
choose between appropriate and available methods.
(5) No procedure must be performed or treatment given against or
independent of a patient’s own will, unless the patient lacks capacity to
express his or her own wishes or, owing to psychiatric illness, cannot see
what is in his or her best interest or, for the same reason, is a severe threat
to others.
In these cases compulsory treatment may or should be given, pro-
vided that it is done in the patient’s best interests and over a reasonable
period of time, a retroactive informed consent can be presumed, and,
 “Declaration of Hawaii” — 331
whenever possible, consent has been obtained from someone close to the
patient.
(6) As soon as the above conditions for compulsory treatment no
longer apply the patient must be released, unless he or she voluntarily con-
sents to further treatment. Whenever there is compulsory treatment or
detention there must be an independent and neutral body of appeal for
regular inquiry into these cases. Every patient must be informed of its exis-
tence and be permitted to appeal to it, personally or through a representa-
tive, without interference by the hospital staff or by anyone else.
(7) The psychiatrist must never use the possibilities of the profession
for maltreatment of individuals or groups, and should be concerned never
to let inappropriate personal desires, feelings, or prejudices interfere with
the treatment.
The psychiatrist must not participate in compulsory psychiatric treat-
ment in the absence of psychiatric illness. If the patient or some third party
demands actions contrary to scientific or ethical principles the psychiatrist
must refuse to co-operate. When, for any reason, either the wishes or the
best interests of the patient cannot be promoted he or she must be so
informed.
(8) Whatever the psychiatrist has been told by the patient, or has
noted during examination or treatment, must be kept confidential unless
the patient releases the psychiatrist from professional secrecy, or else vital
common values or the patient’s best interest makes disclosure imperative.
In these cases, however, the patient must be immediately informed of the
breach of secrecy.
(9) To increase and propagate psychiatric knowledge and skill requires
participation of the patients. Informed consent must, however, be obtained
before presenting a patient to a class and, if possible, also when a case his-
tory is published, and all reasonable measures be taken to preserve the
anonymity and to safeguard the personal reputation of the subject.
In clinical research, as in therapy, every subject must be offered the best
available treatment. His or her participation must be voluntary, after full
information has been given of the aims, procedures, risks, and inconven-
iences of the project, and there must always be a reasonable relationship
between calculated risks or inconveniences and the benefit of the study.
For children and other patients who cannot themselves give informed
consent this should be obtained from someone close to them.
332 — Mental Illness, Psychiatry, and Communism
(10) Every patient or research subject is free to withdraw for any rea-
son at any time from any voluntary treatment and from any teaching or
research programme in which he or she participates. This withdrawal, as
well as any refusal to enter a programme, must never influence the psychi-
atrist’s efforts to help the patient or subject.
The psychiatrist should stop all therapeutic, teaching, or research pro-
grammes that may evolve contrary to the principles of this Declaration.

World Psychiatric Association, “Declaration of Hawaii,” British Medical Journal 2

(1977): 1204–1205. With the kind permission of the WPA Executive Committee.
 Antipsychiatry,
Social Psychiatry, and
Deinstitutionalization
Frantz Fanon
(1925–1961)

“The ‘ North African Syndrome’ ”

(1952)

Frantz Fanon, the son of an upper-middle-class Indian Martinican

father and an Alsatian mother, was born and raised on the
Caribbean island of Martinique. It was in Martinique, a French
colony until 1946, that Fanon first became conscious of the ways in
which a colonial setting shaped people’s identities. In 1947, he went
to France, studying psychiatry in Lyon. Working there, he became
concerned about the numerous North African migrant workers he
encountered who complained of a variety of seemingly inexplicable
ailments. In 1953, he arrived in Algeria, then a French colony, to
better understand the limits of European medicine for non-Western
individuals. His experience in Algeria quickly convinced him that
colonialism possessed its own pathological psychology, which it
passed on to those under its rule. Believing that Western psychia-
try was, therefore, incapable of understanding and remedying the
problems facing the colonized, Fanon left psychiatry in 1956 to
become a political revolutionary and a spokesperson for armed, anti-
colonial insurrection. “The ‘North African Syndrome,’” written at
times in poetic style, is his attempt to analyze psychiatry’s inability
to come to terms with the plight of North African migrant workers
in France.

333
334 — Antipsychiatry, Deinstitutionalization
It is a common saying that man is constantly a challenge to himself, and
that were he to claim that he is no longer he would be denying himself. It
must be possible, however, to describe an initial, a basic dimension of all
human problems. More precisely, it would seem that all the problems
which man faces on the subject of man can be reduced to this one question:
“Have I not, because of what I have done or failed to do, contributed to
an impoverishment of human reality?”
The question could also be formulated in this way:
“Have I at all times demanded and brought out that man that is in me?”
I want to show in what is to follow that, in the specific case of the
North African who has emigrated to France, a theory of inhumanity is in a
fair way to finding its laws and its corollaries.
All those men who are hungry, all those men who are cold, all those
men who are afraid . . .
All those man of whom we are afraid, who crush the jealous emerald of
our dreams, who twist the fragile curves of our smiles, all those men we
face, who ask us no questions, but to whom we put strange ones.
Who are they?
I ask you, I ask myself. Who are they, those creatures starving for
humanity who stand buttressed against the impalpable frontiers (though I
know them from experience to be terribly distinct) of complete recogni-
tion?
Who are they, in truth, those creatures, who hide, who are hidden by
social truth beneath the attributes of bicot, bounioule, arabe, raton, sidi, mon
z’ami?*

first thesis.—That the behavior of the North African often causes a med-
ical staff to have misgiving as to the reality of his illness.
Except in urgent cases—an intestinal occlusion, wounds, accidents—
the North African arrives enveloped in vagueness.
He has an ache in his belly, in his back, he has an ache everywhere. He
suffers miserably, his face is eloquent, he is obviously suffering.
“What’s wrong, my friend?”
“I’m dying, monsiuer le docteur.”
His voice breaks imperceptibly.

*Translator’s note: Terms of contempt applied in France to Arabs in general and to

Algerians in particular.
 Fanon, “The ‘North African Syndrome’ ” — 335
“Where do you have pain?”
“Everywhere, monsieur le docteur.”
You must not ask for specific symptoms: you would not be given any.
For example, in pains of ulcerous character, it is important to know their
periodicity. This conformity to the categories of the time is something to
which the North African seems to be hostile. It is not lack of comprehen-
sion, for he often comes accompanied by an interpreter. It is as though it is
an effort for him to go back to where he no longer is. The past for him is a
burning past. What he hopes is that he will never suffer again, never again
be face to face with the past. This present pain, which visibly mobilizes the
muscles of his face, suffices him. He does not understand that anyone
should wish to impose on him, even by way of memory, the pain that is
already gone. He does not understand why the doctor asks him so many
questions.
“Where does it hurt?”
“In my belly.” (He then points to his thorax and abdomen.)
“When does it hurt?”
“All the time.”
“Even at night.”
“Especially at night.”
“It hurts more at night than in the daytime, does it?”
“No, all the time.”
“But more at night than in the daytime.”
“No, all the time.”
“And where does it hurt now.”
“Here.” (He then points to his thorax and abdomen.)
And there you are. Meanwhile patients are waiting outside and the
worst of it is that you have the impression that time would not improve
matters. You therefore fall back on a diagnosis of probability and in corre-
lation propose an approximate therapy.
“Take this treatment for a month. If you don’t get better, come back
and see me.”
There are then two possibilities:
1. The patient is not immediately relieved, and he comes back after
three or four days. This sets us against him, because we know that it takes
time for the prescribed medicine to have an effect on the lesion. He is made
to understand this, or more precisely, he is told. But our patient has not
336 — Antipsychiatry, Deinstitutionalization
heard what we said. He is his pain and he refuses to understand any lan-
guage, and it is not far from this to the conclusion: It is because I am Arab
that they don’t treat me like others.
2. The patient is not immediately relieved, but he does not go back to
the same doctor, nor to the same dispensary. He goes elsewhere. He pro-
ceeds on the assumption that in order to get satisfaction he has to knock
at every door, and he knocks. He knocks persistently. Gently. Naively.
Furiously.
He knocks. The door is opened. The door is always opened. And he
tells about his pain. Which becomes increasingly his own. He now talks
about it volubly. He takes hold of it in space and puts it before the doctor’s
nose. He takes it, touches it with his ten fingers, develops it, exposes it. It
grows as one watches it. He gathers it over the whole surface of his body
and after fifteen minutes of gestured explanations the interpreter (appro-
priately baffling) translates for us: he says he has a belly-ache.
All these forays into space, all those facial spasms, all those wild stares
were only meant to express a vague discomfort. We experience a kind of
frustration in the field of explanation. The comedy, or the drama, begins all
over again: approximate diagnosis and therapy.
There is no reason for the wheel to stop going around. Some day an X-
ray will be taken of him which will show an ulcer or a gastritis. Or which
in most cases will show nothing at all. His ailment will be described as
“functional.”
This concept is of some importance and is worth looking into. A thing
is said to be vague when it is lacking in consistency, in objective reality. The
North African’s pain, for which we can find no lesional basis, is judged to
have no consistency, no reality. Now the North African is a man-who-does-
n’t-like-work. So that whatever he does will be interpreted a priori on the
basis of this.
A North African is hospitalized because he suffers from lassitude,
asthenia, weakness. He is given active treatment on the basis of restora-
tives. After twenty days it is decided to discharge him. He then discovers
that he has another disease.
“My heart seems to flutter inside here.”
“My head is bursting.”
In the face of this fear of leaving the hospital one begins to wonder if
the debility for which he was treated was not due to some giddiness. One
 Fanon, “The ‘North African Syndrome’ ” — 337
begins to wonder if one has not been the plaything of the patient whom one
has never too well understood. Suspicion rears its head. Henceforth one
will mistrust the alleged symptoms.
The thing is perfectly clear in the winter; so much so that certain wards
are literally submerged by North Africans during the severe cold spells. It’s
so comfortable within hospital walls.
In one ward, a doctor was scolding a European suffering from sciatica
who spent the day visiting in the different rooms. The doctor explained to
him that with this particular ailment, rest constituted one half of the ther-
apy. With the North Africans, he added, for our benefit, the problem is dif-
ferent: there is no need to prescribe rest; they’re always in bed.
In the face of this pain without lesion, this illness distributed in and
over the whole body, this continuous suffering, the easiest attitude, to
which one comes more or less rapidly, is the negation of any morbidity.
When you come down to it, the North African is a simulator, a liar, a
malingerer, a sluggard, a thief.*

second thesis.—That the attitude of medical personnel is very often an a

priori attitude. The North African does not come with a substratum common to
his race, but on a foundation built by the European. In other words, the North
African, spontaneously, by the very fact of appearing on the scene, enters into a pre-
existing framework.
For several years of medicine has shown a trend which, in a very sum-
mary way, we can call neo-Hippocratism. In accordance with this trend doc-
tors, when faced with a patient, are concerned less with making a diagnosis
of an organ than with a diagnosis of a function. But this orientation has not
yet found favor in the medical schools where pathology is taught. There is
a flaw in the practitioner’s thinking. An extremely dangerous flaw.
We shall see how it manifests itself in practice.
I am called in to visit a patient on an emergency. It is two o’clock in the
morning. The room is dirty, the patient is dirty. His parents are dirty.
Everybody weeps. Everybody screams. One has the strange impression that
death is hovering nearby. The young doctor does not let himself be per-
turbed. He “objectively” examines the belly that has every appearance of
requiring surgery.

*Author’s note: Social security? It’s we who pay for it!

338 — Antipsychiatry, Deinstitutionalization
He touches, he feels, he taps, he questions, but he gets only groans by
way of response. He feels again, taps a second time, and the belly contracts,
resists . . . He “sees nothing.” But what if an operation is really called for?
What if he is overlooking something? His examination is negative, but he
doesn’t dare to leave. After considerable hesitation, he will send his patient
to a center with the diagnosis of an abdomen requiring surgery. Three days
later he sees the patient with the “abdomen requiring surgery” turn up
smilingly in his office, completely cured. And what the patient is unaware
of is that there is an exacting medical philosophy, and that he has flouted
this philosophy.
Medical thinking proceeds from the symptom to the lesion. In the illus-
trious assemblies, in the international medical congresses, agreement has
been reached as to the importance of the neurovegetative systems, the di-
encephalon, the endocrine glands, the psychosomatic links, the sympathal-
gias, but doctors continue to be taught that every symptom requires a lesion.
The patient who complains of headaches, ringing in his ears, and dizziness,
will also have high blood-pressure. But should it happen that along with
these symptoms there is no sign of high blood-pressure, nor of brain tumor,
in any case nothing positive, the doctor would have to conclude that med-
ical thinking was at fault; and as any thinking is necessarily thinking about
something, he will find the patient at fault—an indocile, undisciplined
patient, who doesn’t know the rules of the game. Especially the rule, known
to be inflexible, which says: any symptom presupposes a lesion.
What am I to do with this patient? From the specialist to whom I had
sent him for a probable operation, he comes back to me with the diagnosis
of “North African syndrome.” And it is true that the newly arrived medico
will run into situations reminiscent of Molière through the North Africans
he is called upon to treat. A man who fancies himself to be ill! If Molière
(what I am about to say is utterly stupid, but all these lines only explicate,
only make more flagrant, something vastly more stupid), if Molière had had
the privilege of living in the twentieth century, he would certainly not have
written Le Malade Imaginaire, for there can be no doubt that Argan is ill, is
actively ill:
“Comment, conquine! Si je suis malade! Si je suis malade, impudente!”*

*Translator’s note: “What, you hussy! You doubt if I’m sick! You doubt if I’m sick,
you impudent wench!”
 Fanon, “The ‘North African Syndrome’ ” — 339
The North African syndrome. The North African today who goes to
see a doctor bears the dead weight of all his compatriots. Of all those who
had only symptoms, of all those about whom the doctors said, “Nothing
you can put your teeth into.” (Meaning: no lesion.) But the patient who is
here, in front of me, this body which I am forced to assume to be swept by
a consciousness, this body which is no longer altogether a body or rather
which is doubly a body since it is beside itself with terror—this body which
asks me to listen to it without, however, paying too much heed to it—fills
me with exasperation.
“Where do you hurt?”
“In my stomach.” (He points to his liver.)
I lose my patience. I tell him that the stomach is to the left, that what
he is pointing to is the location of the liver. He is not put out, he passes the
palm of his hand over that mysterious belly.
“It all hurts.”
I happen to know that this “it all” contains three organs: more exactly
five or six. That each organ has its pathology. The pathology invented by
the Arab does not interest us. It is a pseudo-pathology. The Arab is a
pseudo-invalid.
Every Arab is a man who suffers from an imaginary ailment. The young
doctor or the young student who has never seen a sick Arab knows (the
medical tradition testifies to it) that “those fellows are humbugs.” There is
one thing that might give food for thought. Speaking to an Arab, the stu-
dent or the doctor is inclined to use the second person singular. It’s a nice
thing to do, we are told . . . to put them at ease . . . they’re used to it . . . I
am sorry, but I find myself incapable of analyzing this phenomenon with-
out departing from the objective attitude to which I have constrained
myself.
“I can’t help it,” an intern once told me, “I can’t talk to them in the
same way that I talk to other patients.”
Yes, to be sure: “I can’t help it.” If you only knew the things in my life
that I can’t help. If you only knew the things in my life that plague me dur-
ing the hours when others are benumbing their brains. If you only knew
. . . but you will never know.
The medical staff discovers the existence of a North African syndrome.
Not experimentally, but on the basis of an oral tradition. The North
African takes his place in this asymptomatic syndrome and is automatically
340 — Antipsychiatry, Deinstitutionalization
put down as undisciplined (cf. medical discipline), inconsequential (with
reference to the law according to which every symptoms implies a lesion),
and insincere (he says he is suffering when we know there are no reasons for
suffering). There is a floating idea which is present, just beyond the limits
of my lack of good faith, which emerges when the Arab unveils himself
through his language:
“Doctor, I am going to die.”
This idea, after having passed through a number of contortions, will
impose itself, will impose itself on me.
No, you certainly can’t take these fellows seriously.

third thesis.—That the greatest willingness, the purest of intentions

require enlightenment. Concerning the necessity of making a situational diagnosis.
Dr. Stern, in an article on psychosomatic medicine, based on the work
of Heinrich Meng, writes: “One must not only find out which organ is
attacked, what is the nature of the organic lesions, if they exist, and what
microbe has invaded the organism; it is not enough to know the ‘somatic
constitution’ of the patient. One must try to find out what Meng calls his
‘situation,’ that is to say, his relations with his associates, his occupations and his
preoccupations, his sexuality, his sense of security or of insecurity, the dangers that
threaten him; and we may add also his evolution, the story of his life. One must
make a ‘situational diagnosis.’ ” *
Dr. Stern offers us a magnificent plan, and we shall follow it.
1. Relations with his associates. Must we really speak of this? Is there not
something a little comical about speaking of the North African’s relation
with his associates, in France? Does he have relations? Does he have associ-
ates? Is he not alone? Are they not alone? Don’t they seem absurd to us,
that is to say without substance, in the trams and the trolleybuses? Where
do they come from? Where are they going? From time to time one sees
them working at some building, but one does not see them, one perceives
them, one gets a glimpse of them. Associates? Relations? There are no con-
tracts. There are only bumps. Do people realize how much that is gentle
and polite is contained in this word, “contact?” Are there contacts? Are
there relations?

*Author’s note: Dr. E. Stern, “Médicine psychosomatique,” Psyché, Jan.–Feb. 1949,

p. 128. Editor’s note: Emphasis added by author.
 Fanon, “The ‘North African Syndrome’ ” — 341
2. Occupations and preoccupations. He works, he is busy, he busies him-
self, he is kept busy. His preoccupations? I think the word does not exist in
his language. What would he concern himself with? In France we say: Il se
préoccupe de trouver du travail (he concerns himself with looking for work);
in North Africa: he busies himself looking for work.
“Excuse me, Madame, but in your opinion, what are the preoccupa-
tions of a North African?”
3. Sexuality. Yes, I know what you mean; it consists of rape. In order
to show to what extent a scotomizing study can be prejudicial to the
authentic unveiling of a phenomenon, I should like to reproduce a few
lines from a doctoral thesis in medicine presented in Lyon in 1951 by Dr.
Léon Mugniery:
“In the region of Saint Etienne, eight out of ten have married prosti-
tutes. Most of the others have accidental and short-time mistresses, some-
times on a marital basis. Often they put up one or several prostitutes for a
few days and bring their friends in to them.
“For prostitution seems to play an important role in the North African
colony.* . . . It is due to the powerful sexual appetite that is characteristic of
those hot-blooded southerners.”
Further on:
“It can be shown by many examples that attempts made to house
North Africans decently have repeatedly failed.
“These are mostly young men (25 to 35) with great sexual needs,
whom the bonds of a mixed marriage can only temporarily stabilize, and for
whom homosexuality is a disastrous inclination. . . .
“There are few solutions to this problem: either, in spite of the risks †
involved in a certain invasion by the Arab family, the regrouping of this
family in France should be encouraged and Arab girls and women should
be brought here; or else houses of prostitutions for them should be toler-
ated . . .
“If these factors are not taken into account, we may well be exposed to
increasing attempts at rape, of the kind that the newspapers are constantly
reporting. Public morals surely have more to fear from the existence of
these facts than from the existence of brothels.”

*Translator’s note: Emphasis added by author.

†
Translator’s note: Emphasis added by author.
342 — Antipsychiatry, Deinstitutionalization
And to conclude, Dr. Mugniery deplores the mistake made by the
French government in the following sentence which appears in capitals in
his thesis: “the granting of french citizenship, conferring
equality of rights, seems to have been too hasty and based on
sentimental and political reasons, rather than on the fact of
the social and intellectual evolution of a race having a civi-
lization that is at times refined but still primitive in its social,
family and sanitary behavior.”
Need anything be added? Should we take up these absurd sentences
one after the other? Should we remind Dr. Mugniery that if the North
Africans in France content themselves with prostitutes, it is because they
find prostitutes here in the first place, and also because they do not find any
Arab women (who might invade the nation)?
4. His inner tension. Utterly unrealistic! You might as well speak of the
inner tension of a stone. Inner tension indeed! What a joke!
5. His sense of security and of insecurity. The first term has to be struck
out. The North African is in a perpetual state of insecurity. A multiseg-
mented insecurity.
I sometimes wonder if it would not be well to reveal to the average
Frenchman that it is a misfortune to be a North African. The North
African is never sure. He has rights, you will tell me, but he doesn’t know
what they are. Ah! Ah! It’s up to him to know them. Yes, sure, we’re back
on our feet! Rights, Duties, Citizenship, Equality, what fine things! The
North African on the threshold of the French Nation—which is, we are
told, his as well—experiences in the political realm, on the plane of citi-
zenship, an imbroglio which no one is willing to face. What connection
does this have with the North African in a hospital setting? It so happens
that there is a connection.
6. The dangers that threaten him. Threatened in his affectivity, threatened
in his social activity, threatened in his membership in the community—the
North African combines all the conditions that make a sick man.
Without a family, without love, without human relations, without
communion with the group, the first encounter with himself will occur in
a neurotic mode, in a pathological mode; he will feel himself emptied, with-
out life, in a bodily struggle with death, a death on this side of death, a death
in life—and what is more pathetic than this man with robust muscles who
tells us in his truly broken voice, “Doctor, I’m going to die”?
 Fanon, “The ‘North African Syndrome’ ” — 343
7. His evolution and the story of his life. It would be better to say the his-
tory of his death. A daily death.
A death in the tram,
a death in the doctor’s office,
a death with the prostitutes,
a death on the job site,
a death at the movies,
a multiple death in the newspapers,
a death in the fear of all decent folks of going out after midnight.
A death,
yes, a death.

All this is very fine, we shall be told, but what solutions do you propose?
As you know, they are vague, amorphous . . .
“You constantly have to be on their backs.”
“You’ve got to push them out of the hospital.”
“If you were to listen to them you would prolong their convalescence
indefinitely.”
“They can’t express themselves.”
And they are liars,
and also they are thieves
and also and also and also
the Arab is a thief
all Arabs are thieves
It’s a do-nothing race
dirty
disgusting
Nothing you can do about them
nothing you can get out of them
sure, it’s hard for them being the way they are
being that way
but anyway, you can’t say it’s our fault.

—But that’s just it, it is our fault.

It so happens that the fault is your fault.
Men come and go along a corridor you have built for them, where you
344 — Antipsychiatry, Deinstitutionalization
have provided no bench on which they can rest, where you have crystal-
lized a lot of scarecrows that viciously smack them in the face, and hurt
their cheeks, their chests, their hearts.
Where they find no room
where you leave them no room
where there is absolutely no room for them
and you dare tell me it doesn’t concern you!
that it’s no fault of yours!

This man whom you thingify by calling him systematically Moham-

med, whom you reconstruct, or rather whom you dissolve, on the basis of
an idea, an idea you know to be repulsive (you know perfectly well you rob
him of something, that something for which not so long ago you were ready
to give up everything, even your life) well, don’t you have the impression
that you are emptying him of his substance?
Why don’t they stay where they belong?
Sure! That’s easy enough to say: why don’t they stay where they
belong? The trouble is, they have been told they were French. They learned
it in school. In the street. In the barracks. (Where they were given shoes
to wear on their feet.) On the battlefields. They have had France squeezed
into them wherever, in their bodies and in their souls, there was room for
something apparently great.
Now they are told in no uncertain terms that they are in “our” coun-
try. That if they don’t like it, all they have to do is go back to their Casbah.
For here too there is a problem.
Whatever vicissitudes he may come up against in France, so some peo-
ple claim, the North African will be happier at home . . .
It has been found in England that children who were magnificently fed,
each having two nurses entirely at his services, but living away from the
family circle, showed a morbidity twice as pronounced as children who
were less well fed but who lived with their parents. Without going so far,
think of all those who lead a life without a future in their own country and
who refuse fine positions abroad. What is the good of a fine position if it
does not culminate in a family, in something that can be called home?
Psychoanalytical science considers expatriation to be a morbid phe-
nomenon. In which it is perfectly right.
 Fanon, “The ‘North African Syndrome’ ” — 345
These considerations allow us to conclude:
1. The North African will never be happier in Europe than at home, for
he is asked to live without the very substance of his affectivity. Cut off from
his origins and cut off from his ends, he is a thing tossed into the great
sound and fury, bowed beneath the law of inertia.
2. There is something manifestly and abjectly disingenuous in the
above statement. If the standard of living made available to the North
African in France is higher than the one he was accustomed to at home,
this means that there is still a good deal to be done in his country, in that
“other part of France.”
That there are houses to be built, schools to be opened, roads to be laid
out, slums to be torn down, cities to be made to spring from the earth, men
and women, children and children to be adorned with smiles.
This means that there is work to be done over there, human work, that
is, work which is the meaning of a home. Not that of a room or a barrack
building. It means that over the whole territory of the French nation (the
metropolis and the French Union), there are tears to be wiped away, in-
human attitudes to be fought, condescending ways of speech to be ruled
out, men to be humanized.
Your solution, sir?
Don’t push me too far. Don’t force me to tell you what you ought to
know, sir. If you do not reclaim the man who is before you, how can I
assume that you reclaim the man that is in you?
If you do not want the man who is before you, how can I believe the
man that is perhaps in you?
If you do not demand the man, if you do not sacrifice the man that is
in you so that the man who is on this earth shall be more than a body, more
than a Mohammed, by what conjurer’s trick will I have to acquire the cer-
tainty that you, too, are worthy of my love?

From Frantz Fanon, “The North African Syndrome,” Toward the African Revolution:
Political Essays, translated by Haakon Chevalier (New York: Grove/Atlantic, 1967),
3–16. Copyright © 1964 by François Maspero. Used by permission of
Grove/Atlantic, Inc.
346 — Antipsychiatry, Deinstitutionalization

Thomas Szasz
(b. 1920)

“The Myth of Mental Illness”

(1960)

Against the backdrop of the end of World War II, the beginning of
postwar prosperity in the United States and Western Europe, and
the rise of new social protest movements, a number of public intel-
lectuals, mental health professionals, and psychiatric patients and
their relatives began questioning some of the most basic assump-
tions of psychiatry and psychotherapy. By the mid-1970s, their par-
ticular criticisms and activism became known as the antipsychiatry
movement. The leading voices of antipsychiatry were often psychi-
atrists, psychotherapists, and social scientists who themselves had
become disillusioned with the conventional values and methods of
mental health care. They and their allies took it upon themselves to
publicly criticize such things as the treatment of deviant behavior
and mental states as diseases, the professional dominance of physi-
cians, the practice of institutionalization, and the use of psy-
chopharmaceuticals in treating personal problems. To this day,
antipsychiatry’s reception has been marked by both enthusiastic
support and resolute dismissal.
In the United States at least, no name is more closely associated
with the antipsychiatry movement than that of Thomas Szasz. Born
in Budapest, Szasz came to the United States in 1938, where he
earned an MD and trained in psychoanalysis. He is a prolific author,
and his works—beginning with his book The Myth of Mental Illness,
first published in 1961—and his libertarian views about psychiatry
have made him an influential, yet polarizing, public figure for almost
fifty years.

My aim in this essay is to raise the question “Is there such a thing as men-
tal illness?” and to argue that there is not. Since the notion of mental illness
is extremely widely used nowadays, inquiry into the ways in which this
 Szasz, “The Myth of Mental Illness” — 347
term is employed would seem to be especially indicated. Mental illness, of
course, is not literally a “thing”—or physical object—and hence it can
“exist” only in the same sort of way in which other theoretical concepts
exist. Yet, familiar theories are in the habit of posing, sooner or later—at
least to those who come to believe in them—as “objective truths” (or
“facts”). During certain historical periods, explanatory conceptions such as
deities, witches, and microorganisms appeared not only as theories but as
self-evident causes of a vast number of events. I submit that today mental
illness is widely regarded in a somewhat similar fashion, that is, as the cause
of innumerable diverse happenings. As an antidote to the complacent use
of the notion of mental illness—whether as a self-evident phenomenon,
theory, or cause—let us ask this question: What is meant when it is
asserted that someone is mentally ill?
In what follows I shall describe briefly the main uses to which the con-
cept of mental illness has been put. I shall argue that this notion has out-
lived whatever usefulness it might have had and that it now functions
merely as a convenient myth.

Mental Illness as a Sign of Brain Disease

The notion of mental illness derives it [sic] main support from such phe-
nomena as syphilis of the brain or delirious conditions—intoxications, for
instance—in which persons are known to manifest various peculiarities or
disorders of thinking and behavior. Correctly speaking, however, these are
diseases of the brain, not of the mind. According to one school of thought,
all so-called mental illness is of this type. The assumption is made that
some neurological defect, perhaps a very subtle one, will ultimately be
found for all the disorders of thinking and behavior. Many contemporary
psychiatrists, physicians, and other scientists hold this view. This position
implies that people cannot have troubles—expressed in what are now called
“mental illnesses”—because of differences in personal needs, opinions,
social aspirations, values, and so on. All problems in living are attributed to
physicochemical processes which in due time will be discovered by medical
research.
“Mental illnesses” are thus regarded as basically no different than all
other diseases (that is, of the body). The only difference, in this view,
between mental and bodily diseases is that the former, affecting the brain,
348 — Antipsychiatry, Deinstitutionalization
manifest themselves by means of mental symptoms; whereas the latter,
affecting other organ systems (for example, the skin, liver, etc.), manifest
themselves by means of symptoms referable to those parts of the body. This
view rests on and expresses what are, in my opinion, two fundamental
errors.
In the first place, what central nervous system symptoms would corre-
spond to a skin eruption or a fracture? It would not be some emotion or
complex bit of behavior. Rather, it would be blindness or a paralysis of
some part of the body. The crux of the matter is that a disease of the brain,
analogous to a disease of the skin or bone, is a neurological defect, and not
a problem in living. For example, a defect in a person’s visual field may be
satisfactorily explained by correlating it with certain definite lesions in the
nervous system. On the other hand, a person’s belief—whether this be a
belief in Christianity, in Communism, or in the idea that his internal organs
are “rotting” and that his body is, in fact, already “dead”—cannot be
explained by a defect or disease of the nervous system. Explanations of this
sort of occurrence—assuming that one is interested in the belief itself and
does not regard it simply as a “symptom” or expression of something else
that is more interesting—must be sought along different lines.
The second error in regarding complex psychosocial behavior, consist-
ing of communications about ourselves and the world about us, as mere
symptoms of neurological functioning is epistemological. In other words, it
is an error pertaining not to any mistakes in observation or reasoning, as
such, but rather to the way in which we organize and express our knowl-
edge. In the present case, the error lies in making a symmetrical dualism
between mental and physical (or bodily) symptoms, a dualism which is
merely a habit of speech and to which no known observations can be found
to correspond. Let us see if this is so. In medical practice, when we speak
of physical disturbances, we mean either signs (for example, a fever) or
symptoms (for example, pain). We speak of mental symptoms, on the other
hand, when we refer to a patient’s communications about himself, others, and
the world about him. He might state that he is Napoleon or that he is being
persecuted by the Communists. These would be considered mental symp-
toms only if the observer believed that the patient was not Napoleon or that
he was not being persecuted by the Communists. This makes it apparent
that the statement that “X is a mental symptom” involves rendering a judg-
ment. The judgment entails, moreover, a covert comparison or matching of
 Szasz, “The Myth of Mental Illness” — 349
the patient’s ideas, concepts, or beliefs with those of the observer and the
society in which they live. The notion of mental symptom is therefore inex-
tricably tied to the social (including ethical) context in which it is made in
much the same way as the notion of bodily symptom is tied to an anatomi-
cal and genetic context.
To sum up what has been said thus far: I have tried to show that for
those who regard mental symptoms as signs of brain disease, the concept
of mental illness is unnecessary and misleading. For what they mean is that
people so labeled suffer from diseases of the brain; and, if that is what they
mean, it would seem better for the sake of clarity to say that and not some-
thing else.

Mental Illness as a Name for Problems in Living

The term “mental illness” is widely used to describe something which is

very different than a disease of the brain. Many people today take it for
granted that living is an arduous process. Its hardship for modern man,
moreover, derives not so much from a struggle for biological survival as
from the stresses and strains inherent in the social intercourse of complex
human personalities. In this context, the notion of mental illness is used to
identify or describe some feature of an individual’s so-called personality.
Mental illness—as a deformity of the personality, so to speak—is then
regarded as the cause of the human disharmony. It is implicit in this view
that social intercourse between people is regarded as something inherently
harmonious, its disturbance being due solely to the presence of “mental ill-
ness” in many people. This is obviously fallacious reasoning, for it makes
the abstraction “mental illness” into a cause, even though this abstraction
was created in the first place to serve only as a shorthand expression for cer-
tain types of human behavior. It now becomes necessary to ask: “What
kinds of behavior are regarded as indicative of mental illness, and by
whom?”
The concept of illness, whether bodily or mental, implies deviation from
some clearly defined norm. In the case of physical illness, the norm is the
structural and functional integrity of the human body. Thus, although the
desirability of physical health, as such, is an ethical value, what health is can
be stated in anatomical and physiological terms. What is the norm devia-
tion from which is regarded as mental illness? This question cannot be
350 — Antipsychiatry, Deinstitutionalization
easily answered. But whatever this norm might be, we can be certain of
only one thing: namely, that it is a norm that must be stated in terms of psy-
chosocial, ethical, and legal concepts. For example, notions such as “excessive
repression” or “acting out an unconscious impulse” illustrate the use of
psychological concepts for judging (so-called) mental health and illness.
The idea that chronic hostility, vengefulness, or divorce are indicative of
mental illness would be illustrations of the use of ethical norms (that is, the
desirability of love, kindness, and a stable marriage relationship). Finally,
the widespread psychiatric opinion that only a mentally ill person would
commit homicide illustrates the use of a legal concept as a norm of mental
health. The norm from which deviation is measured whenever one speaks
of a mental illness is a psychosocial and ethical one. Yet, the remedy is sought
in terms of medical measures which—it is hoped and assumed—are free
from wide differences of ethical value. The definition of the disorder and the
terms in which its remedy are sought are therefore at serious odds with one
another. The practical significance of this covert conflict between the
alleged nature of the defect and the remedy can hardly be exaggerated.
Having identified the norms used to measure deviations in cases of
mental illness, we will now turn to the question: “Who defines the norms
and hence the deviation?” Two basic answers may be offered: (a) It may be
the person himself (that is, the patient) who decides that he deviates from
a norm. For example, an artist may believe that he suffers from a work
inhibition; and he may implement this conclusion by seeking help for him-
self from a psychotherapist, (b) It may be someone other than the patient
who decides that the latter is deviant (for example, relatives, physicians,
legal authorities, society generally, etc.). In such a case a psychiatrist may
be hired by others to do something to the patient in order to correct the
deviation.
These considerations underscore the importance of asking the ques-
tion “Whose agent is the psychiatrist?” and of giving a candid answer to it.
The psychiatrist (psychologist or nonmedical psychotherapist), it now
develops, may be the agent of the patient, of the relatives, of the school, of
the military services, of a business organization, of a court of law, and so
forth. In speaking of the psychiatrist as the agent of these persons or organ-
izations, it is not implied that his values concerning norms, or his ideas and
aims concerning the proper nature of remedial action, need to coincide
exactly with those of his employer. For example, a patient in individual psy-
 Szasz, “The Myth of Mental Illness” — 351
chotherapy may believe that his salvation lies in a new marriage; his psy-
chotherapist need not share this hypothesis. As the patient’s agent, how-
ever, he must abstain from bringing social or legal force to bear on the
patient which would prevent him from putting his beliefs into action. If his
contract is with the patient, the psychiatrist (psychotherapist) may disagree
with him or stop his treatment; but he cannot engage others to obstruct the
patient’s aspirations. Similarly, if a psychiatrist is engaged by a court to
determine the sanity of a criminal, he need not fully share the legal author-
ities’ values and intentions in regard to the criminal and the means available
for dealing with him. But the psychiatrist is expressly barred from stating,
for example, that it is not the criminal who is “insane” but the men who
wrote the law on the basis of which the very actions that are being judged
are regarded as “criminal.” Such an opinion could be voiced, of course, but
not in a courtroom, and not by a psychiatrist who makes it his practice to
assist the court in performing its daily work.
To recapitulate: In actual contemporary social usage, the finding of a
mental illness is made by establishing a deviance in behavior from certain
psychosocial, ethical, or legal norms. The judgment may be made, as in
medicine, by the patient, the physician (psychiatrist), or others. Remedial
action, finally, tends to be sought in a therapeutic—or covertly medical—
framework, thus creating a situation in which psychosocial, ethical, and/or
legal deviations are claimed to be correctible by (so-called) medical action.
Since medical action is designed to correct only medical deviations, it seems
logically absurd to expect that it will help solve problems whose very exis-
tence had been defined and established on nonmedical grounds. I think that
these considerations may be fruitfully applied to the present use of tran-
quilizers and, more generally, to what might be expected of drugs of what-
ever type in regard to the amelioration or solution of problems in human
living.

From Thomas Szasz, “The Myth of Mental Illness,” American Psychologist 15

(1960): 113–118.
352 — Antipsychiatry, Deinstitutionalization

Franco Basaglia
(1924–1980)

“The Problem of the Incident”

(1968)

Like many European countries, Italy of the 1950s continued to have

institutions and legal codes governing psychiatric care that dated
back to before World War I. As critical voices emerged, the first
efforts to reform the existing system began at the local level, outside
academia. One of the first and most influential experiments began
in 1961 in the northeastern Italian town of Gorizia, where the psy-
chiatrist Franco Basaglia brought his unconventional ideas and a
team of like-minded professionals to reform the mental hospital
there. Inspired by the philosophies of existentialism, phenomenol-
ogy, and the therapeutic community, Basaglia moved to realize his
ideal of the “open hospital.” Under his directorship, Gorizia abol-
ished restraints, patients were allowed to wear street clothes, elec-
troshock was suspended, medications were reduced, and regular
staff-patient assemblies were introduced.
Over time, Basaglia came to the conclusion that patients could
never be fully reintegrated into society through treatment in an
asylum. In 1971, he began a comprehensive reform of psychiatric
treatment in Trieste, shifting services from inpatient to outpatient
care in the community. By the early-1970s, similar experiments
were going on all over Italy under the rubric “democratic psychia-
try.” These local and regional initiatives eventually culminated in
1978 in the Italian parliament’s passage of Law Number 180,
which placed strong restrictions on the use of involuntary methods
of commitment and treatment and mandated that outpatient serv-
ices play the primary role in care. The law had its effect: while in
1970, there were 82.5 public psychiatric hospital residents per
100,000 of the adult population in Italy, the figure fell to 30.7 by
1984.
 Basaglia, “The Problem of the Incident” — 353
Any violent incident that occurs in a psychiatric institution is immediately
attributed to the patient’s illness,* the presumed single cause of unpre-
dictable behaviors there. Insofar as psychiatry has defined the mental
patient as incomprehensible, the psychiatrist, who is legally bound to
supervise and protect the patient, is permitted to abdicate all responsibility
for violent or seemingly chaotic behaviors. The psychiatrist is responsible
to society, which has delegated to him the control of abnormal and deviant
behavior along with the means for transferring to the illness all responsi-
bility for those behaviors, without taking into account therapeutic risks
and failures as in all other branches of biomedicine. The psychiatrist’s task
consists of reducing the patient’s subjective experience to a minimum by
totally objectifying her within an institutional system oriented to provid-
ing against the unanticipated, the unforeseeable. The psychiatrist secures
his control of the situation by firmly establishing institutional roles
through legal maneuvers (the jurisdiction of the Attorney General),
administrative regulations (that concern relations with the Provincial
Administration), and scientific nosologies that define the patient’s chronic
malaise.
In this institutional space where abnormality is normative, the unruly,
unbalanced, or disturbed patient is tolerated and excused according to the
gross stereotypes of mental illness, just as, in the same way, murder, sui-
cide or sexual assaults in more open institutions are justified and explained
as expressions of the unknown, unpredictable mechanisms of psychiatric
syndromes. Hence, neither psychiatrist nor the environment can be held
accountable for what are defined as incomprehensible acts. The abnormal
and uncontrollable impulses of the disease are considered sufficiently
explanatory.
However, once we become closer to the patient, no longer viewing
him as an isolated entity enclosed within an incomprehensible world, but
rather as an individual forcibly removed from the social reality to which
he once belonged, and uprooted by an institution that assigns him only a
passive role, then the institution itself becomes implicated in his behav-
ior. Every event becomes reconnected to the environment in which he
lives.

*Translator’s note: The word incidente may be translated as “incident” or “acci-

dent.” The term used here varies according to context.
354 — Antipsychiatry, Deinstitutionalization
The problem of the incident can therefore be considered from two con-
trasting perspectives, each corresponding to the different ways the institu-
tion views the patient.
The primary goal of the classic, closed, custodial institution is efficiency
and the patient is, therefore, treated primarily as an object. If the patient
wants to survive the abuse and destructive power the institution inflicts on
her, she must identify with its norms and rules. Whether she conforms to
it with servile and submissive behavior or whether she resists it with
deviant and insolent behavior, the patient is nonetheless determined by the
institution. The rigidity of its rules and the one-dimensionality of its real-
ity continue to lock her into a passive and dependent role that allows no
alternatives beyond objectification and adaptation.
Thus it is that by establishing a reality with no alternatives other than
regimentation and fragmentation that the institution dictates to the patient
how she must presumably act. These signals are implicit in the absence of
any goals or a future for the patient, which in turn reflects the absence of
any alternatives, goals, or future for the psychiatrist, who is appointed by
society to control abnormal behavior with a minimum of risk.
Everything in this coercive environment is provided for and controlled
in order to avoid that which must not happen. In a reality that exists solely to
prevent it, freedom can only be experienced as a forbidden act, impossible to
achieve. The shaft of light from an open door, the unguarded room, the
half-open window, the knife left lying about, all present an open invitation
to destruction. The patient’s identification with the institution means that
he can only interpret freedom as an act of violence against himself or oth-
ers. This is the message and the logic of the institution. Where there are
no alternatives and no possibility of autonomous behavior, the only future
is death. Death presents itself as a rejection of an unbearable life; as a
protest against objectification; as an illusion of freedom; as, in short, the
only possible plan. It is far too easy to see this death wish as part of the
nature of the illness, as traditional psychiatry would have us believe.
In this context, every action that in some way breaks the iron grip of
the institutional regime gives an illusion of freedom, but is nonetheless
equivalent to death. The escape from an institution is an attempt to avoid
that other future which is death and to experience the sensation of con-
trolling one’s destiny. But inevitably the escape ends in capture and con-
tinued enslavement or in a death.
 Basaglia, “The Problem of the Incident” — 355
Paradoxically, the only responsibility that the institution attributes to
the patient is responsibility for the incident which it hastens to blame on
the patient and his illness, rejecting any connection to, or participation in,
the tragedy. The patient, who has been stripped of all responsibility
throughout the long hospital stay suddenly finds himself totally responsible
for his one “free” act, which almost always coincides with his death. The
closed asylum, a dead world that objectifies patients with dehumanizing
rules, offers only one clear alternative: death, as the illusion of freedom. In
this sense, any accident is merely the expression of a patient’s experiencing
institutional regulation to the bitter end, taking its message to its most log-
ical final conclusion.
We could shift this discussion from hospitalized mental patients to any
people without alternatives, without a future, who cannot find a place for
themselves in the world. Their exclusion indicates to them the only pos-
sible step to take—an act of rejection and destruction.
In the case of the open institution the goal is to try to maintain the
patient’s subjectivity, even if this is to the detriment of general organizational
efficiency. This goal is reflected in every institutional act. When there is a
need for patients to identify with the institution, they identify because they
see their personal goals and their future reflected in it. It is an open world
which offers alternatives and a real sense of possibility to the patients.
In this environment, freedom becomes the norm and the patient
becomes accustomed to exercising it, which means taking responsibility,
self-control, managing one’s life, and understanding one’s illness, without
the biases of medical science. For this to occur, the institution must be
totally involved in the material and psychological support of the patient.
This entails breaking the rigidity of roles; ending the objectifying relation-
ships where one person’s values are taken for granted, while the other’s are
not even recognized as values; the creation of alternatives that allow the
patient to fight against the closed world of institutional rules, and that give
him a sense of existing in a space that fosters continued existence. This
means that the only way the institution will now protect itself is through
the participation of all its members in developing a community, in which
institutional limits are set by the presence of the community and the pos-
sibility of reciprocal struggle.
This is, of course, a utopian description of an open institution. There
are contradictions within such a reality just as there are outside it. What is
356 — Antipsychiatry, Deinstitutionalization
essential is that the institution does not try to mask or hide the contradic-
tions, but rather tries to face them with the patients and point them out
when they are not immediately obvious.
In this context, the incident is no longer the tragic result of a lack of
supervision, but rather an indication of the institution’s lack of support. The
actions of the patients, nurses, and doctors can sometimes fail or there can
be discontinuities where accidents can still occur. Omissions, commis-
sions, failures, and betrayals of trust have logical consequences, but in all
these instances the illness plays a relatively minor role.
The open door becomes a clue to understanding what the door—and
the isolation and exclusion of patients—mean in our society. The open
door acquires a symbolic value as the patient comes to realize that perhaps
he is not after all dangerous to himself and to others. This discovery then
leads him to ask why he has been forced into such disgraced and excluded
conditions in the first place.
In this way the open institution fosters the patient’s recognition that he
really is excluded. Its sole symbolic function is to demonstrate what has
been done to the patient and the social significance of the institution that
has locked him up.
On the other hand, the open door represents a contradiction in a soci-
ety that bases its safety and equilibrium on rigid and tight social categories
that maintain a division of classes and roles. Psychiatrists and nurses
inevitably become aware of this contradiction as they find themselves in sit-
uations where they are part accomplice, part victim, forced to uphold a
social order they now want to destroy. The open door makes the psychia-
trist aware of his own enslavement to a system for which he serves as the
silent, unknowing double agent.
What possible meaning do escapes and accidents have in this context?
They are directly related to the institution’s degree of openness to the out-
side world and to the social nature of that world. The alternatives that the
open institution offer can still come up against society’s refusal to carry
them out. The open door leads, inevitably, to the outside world where soci-
ety and its violent rules, its discriminations, and abuses continue to reject,
deny, exploit, and exclude the mentally ill, who represent one of many dis-
turbing elements for whom public institutions exist.
In such a situation, who is responsible for unfortunate incidents? A
mental patient can be released and then find that he is rejected by his fam-
 Better Services for the Mentally Ill — 357
ily, friends, and co-workers—by a reality that violently dismisses him as
superfluous. What can he do except either kill himself or whomever sym-
bolizes that violence against him? When this happens can we really speak
only in terms of mental illness or of “accidents?”

From Franco Basaglia, “The Problem of the Incident,” translated by Teresa Shtob,
in Psychiatry Inside Out: Selected Writings of Franco Basaglia, edited by Nancy
Scheper-Hughes and Anne M. Lovell (New York: Columbia University Press,
1987), 87–91. Translated by Teresa Shtob. Copyright © 1987 Columbia University
Press. Reprinted with permission of the publisher.

Department of Health and

Social Security, Great Britain
Better Services for the Mentally Ill
(1975)

Deinstitutionalization refers to a process by which large numbers of

psychiatric patients are moved out of public asylums and into a vari-
ety of other community and institutional settings. Historically, the
beginning of deinstitutionalization is often associated with the gen-
eral introduction of the antipsychotic medication chlorpromazine
(also known as Thorazine) in the mid-1950s, which enabled more
chronically disturbed patients to be released more easily. But a num-
ber of social, institutional, and political changes dating back to
World War II led to an emptying of overcrowded asylums across
Europe, Australia and New Zealand, and North America. The
results were striking. In the United States, for instance, there were
around 558,000 patients in public psychiatric facilities in 1955; by
1994, that figure was less than 72,000.
Deinstitutionalization was both a cause and an effect of a change
in thinking about how to understand and treat mental disorders. By
the 1970s, states began setting up commissions and task forces to
both assess progress as well as map future plans in mental health
358 — Antipsychiatry, Deinstitutionalization
care. In 1975, the British secretary of state for social services issued
a white paper, intended to provide the British government with a
strategic plan for carrying on the work of previous decades. Three
new principles were to serve as orientation points: the integration
of mental health services, an emphasis on community care, and the
adoption of a team approach.

The Needs of the Mentally Ill

. . . [C]linical labels reveal relatively little about what it means to be men-

tally ill or to live with someone who is afflicted, or by implication what the
needs of the mentally are in terms of services. In one sense it is misleading
to attempt any generalised statement about the needs of the mentally ill.
The needs of any one mentally ill person are always different from another
even though they may have the same diagnostic label. It is not merely that
need depends on factors such as age, whether there is home support or a
sympathetic employer, but rather that the manifestation of the illness itself
will to some extent be coloured by the personality and home environment
of the individual. Viewed from the individual level, need is personal and it
is important that those working with the patient should see his problems
in this way. At the same time these individual perspectives should not mask
the significance either of the clinical factors whose identification is funda-
mental to scientific classification, or of those needs for certain kinds of help
which the mentally ill have in common, which are discussed below, and
which form the basis of any attempt at national or local planning of services
for them. We must aim, therefore, at a range of facilities which can be used
by professional staff to provide for each individual the particular combina-
tion of care, treatment and support he needs at any point in time.
Not only does need vary qualitatively between different individuals, it
varies quantitatively, especially in the length of time for which support and
treatment may be required. Much emphasis has been laid, and rightly, on
the revolution which has taken place in the treatment of the mentally ill in
recent years. This has meant that for many mentally ill people, psychiatric
treatment need mean no more than a spell of out-patient or day patient vis-
its or a very few weeks as an in-patient. Nevertheless, there will remain
some people who, although their more acute symptoms can be relieved, will
 Better Services for the Mentally Ill — 359
need more or less permanent medical, social and nursing support in a shel-
tered environment. While this group may be relatively few in number their
needs must be recognised, especially as the implications in terms of
resources are quite disproportionate to their numbers. Another important
group are those with mental illness symptoms related to old age. Increasing
longevity is bringing its own problems in this respect.

Prevention

In the absence of more precise knowledge primary prevention can only be

considered in the rather broad terms of reducing the exposure of individu-
als to those circumstances and conditions which are likely to place their
mental health at risk. Healthy physical, mental and emotional development
in childhood is obviously particularly important. Reference has been made
already to the wide range of social and environmental conditions which
may increase vulnerability to mental illness. The precise weight to be
attached to them can rarely be established: poverty, unemployment, lack of
job satisfaction and poor working conditions, bad housing, are themselves
often a cause of marital stress and breakdown in family life. For some of
these central and local authority has a responsibility: but it would be wrong
to pretend that we are anywhere near being able to draw up a positive plan
for a society conducive to mental health.
Nevertheless we can take some steps to put right some of the clearly
unsatisfactory aspects of our social environment. In the field of employ-
ment for example, the Employment Medical Advisory Service of the Health
and Safety Executive has created a senior appointment in mental health to
examine the problems of stress in modern industrial life and offer advice to
industry and the unions. It is anticipated that a small team of specialists will
be available to undertake surveys and studies, and arrange for appropriate
research work with outside bodies such as the Medical Research Council.
In this area, the Employment Medical Advisory Service will co-operate
closely with the Work Research Unit of the Department of Employment,
set up in 1974 to assist organisations in taking practical steps towards
increasing the quality of working life by improving the design of jobs and
organisation of work. Similarly in its approach to housing problems the
Government has taken steps, notably through the Housing Act 1974, to
ensure that resources are concentrated on the areas of greatest stress.
360 — Antipsychiatry, Deinstitutionalization
Employers, managers, environmental planners all need to bear in mind
the potential impact of their decisions on people’s mental well-being. The
lessons of high rise flats are an illustration: and it to be hoped that local
housing authorities in particular will increasingly take into account the
question of mental health when considering the effect of new development
on existing communities. Rarely will there be easy answers, but it is a
dimension of planning which should be acknowledged.
The growth of a wide variety of community development and self
help schemes, clubs and societies is particularly encouraging. Such
organisations can help provide a whole range of help which though per-
haps not specifically directed at mental health have an important part to
play in providing those at risk with additional psychological or social
resources. Marriage guidance, vocational guidance, clubs and recre-
ational facilities, church and voluntary organisations, education for
leisure and retirement, are all relevant. Organisations and services which
are specifically aimed to help in particular crises such as marital break-
down, pregnancy, bereavement, retirement or redundancy are of special
importance. Collectively and individually we each have a responsibility
to be sensitive to the emotional and psychological needs of those who
are vulnerable.

Early Recognition

The individual himself may be unaware of his condition. Those around

him and even professional staff may not recognise it initially. Mental ill-
ness may often be hidden beneath a wide variety of presenting problems:
an ostensibly physical complaint, marital and family problems, quarrels
with neighbours, accident proneness at work and delinquency may all
have their roots in mental illness. Moreover sometimes the person for
whom help is apparently sought may not be the only one in need of pro-
fessional support: the parents, for example, of a disturbed child may them-
selves require psychiatric help. Service must be organised and
professional staff trained to recognise the early stages of psychiatric dis-
turbance and to arrange referral to the appropriate services. Early inter-
vention may often serve to prevent the condition deteriorating to the
point at which a severe crisis occurs and hospital admission becomes the
only possible solution.
 Better Services for the Mentally Ill — 361
Assessment

Assessment of needs must take account of the effects of mental illness on

almost every aspect of a person’s life. It should be a continuing process
involving all the professions concerned, aimed at reducing as swiftly as pos-
sible the damaging effects of illness. The importance of multiprofessional
assessment lies not least in the interchange of views between assessors. Not
only is this essential in the development of an accurate, broad based assess-
ment, but the assessment by each individual discipline is often influenced
by those of others. . . .

Social Rehabilitation

Mental illness often fundamentally affects social adjustment, even after the
primary symptoms of the illness have been treated. The sufferer may lack
his former energy and drive; and have difficulty in making or resuming per-
sonal friendships or family relationships. He may have lost the power of
sustained concentration; and the ability to organise even relatively simple
daily routines may have to be relearnt. If he is to resume his place in a busy
competitive society he will need help in regaining social skills which in the
ordinary fit person are taken for granted. The loss of such skills even for a
short period of time may have far reaching repercussions. A person recov-
ering from mental illness may well not be able to bear the full responsibil-
ity of organising his life.
Social rehabilitation has also to be considered from the standpoint of
the community in the wider sense. The pace of development of community
service for the mentally ill is dependent partly on changes in attitude by the
community. It is also dependent on the community’s capacity to adjust to
the implications of community care for other groups—for example, the
mentally handicapped, the physically handicapped, the elderly mentally
infirm. We must ensure that the community is not itself overwhelmed.

Help for the Family

Living with people who have had or who are recovering from mental illness
can place heavy strains on a family. The mentally ill do not always fit easily
into the family circle or adapt to the family routine: meal times, social
362 — Antipsychiatry, Deinstitutionalization
activities, entertaining may be disrupted and the family can rapidly become
socially isolated. If the mother is ill, the father may find himself having to
take time off work and the family income may fall. Special arrangements
may need to be made for the care of the children. Research studies have
already shown that the children of mentally ill parents are themselves more
likely to suffer from mental illness. The family may become afraid to leave
a withdrawn and uncommunicative member alone; and they too may
become virtually housebound, often giving up sources of income and inter-
est. Under such stresses the family member may become torn between
their determination not to reject the individual member, and a desperate
need for relief and support. Feelings of guilt may be accentuated where
there are brothers and sisters living at home, competing for their parents’
attention and resentful of the way in which their own lives and friendships
are disrupted.
Some families may be able—and indeed wish—to undertake the
demanding task of care. But in these cases it is essential that they receive
support and advice from professional staff and that services should be
organised to give them effective relief: to enable them to go on holiday and
to cope with more urgent domestic crises which may make continued care
impractical from time to time, or simply to allow them some respite from
the sheer physical and emotional strain.

Development in Services for the Mentally Ill

the victorian inheritance

The facilities we have at present to serve the mentally ill are largely an
inheritance bequeathed to us by the Victorians. Of the 100 or so hospitals
providing treatment solely for the mentally ill now in existence, most were
built in the nineteenth century and some have an even longer history. Most
are very large—a number were built to accommodate 2000 or more
patients; and were deliberately built in areas which were then, and in many
cases still are, isolated and remote from centres of population. The aim was
twofold; partly to protect society by providing custodial care behind locked
doors and high walls and partly to protect the patient by providing him
with a secure shelter. A remote site in the country was therefore desirable
on both counts, and had the added advantage that it enabled many patients
to have the benefit of wholesome work in the open air. In an era which
 Better Services for the Mentally Ill — 363
lacked modern medicine, had but the most rudimentary welfare services
and no system of social security payments, the large mental hospital was
designed to be as far as possible a self-sufficient community meeting the
patient’s need at once for care and custody.

the drugs revolution of the 1950s

From the time these hospitals were built and right up to the year 1954,
the number of resident patients in mental illness hospitals went on
steadily increasing save for a small temporary reduction during each of
the two World Wars. No new mental illness hospitals were however
built after the 1930s and by the early 1950s many were becoming
severely overcrowded. Serious thought was then being given to the need
to build new mental hospitals; but fortunately the first half of the 1950s
saw major developments in drug treatment, in particular with the drug
group known as the phenothiazines. The particular significance of these
drugs lay in the fact that they enabled doctors to control the disturbed
behavior of the psychotic patient. As a result not only was the need for
locked doors greatly reduced, but it was also possible for doctors and
nurses to develop contact with patients who had hitherto been almost
entirely cut off from the real world around them by their psychotic ill-
ness. These drugs did not cure illness: but they did enable symptoms to
be controlled and relieved and hence made it possible to prevent or at
least reduce to a considerable extent the social and personal deteriora-
tion accompanying prolonged psychotic illness. The discovery of pheno-
thiazines, and more recently the long acting derivatives, was important
but one should not underestimate the significance of other develop-
ments: changes in staff attitudes; the introduction of non-physical
approaches to treatment; the development of social security and other
forms of support outside hospital. Together these developments led to
what has been called the “open-door” policy. The function of the hospi-
tal was seen increasingly as being for treatment and rehabilitation rather
than care and control. With the growing realisation that so many patients
could be treated as day patients or out-patients, admission for long term
in-patient treatment became less necessary. This changing approach also
led to the development of small psychiatric units in general hospitals for
treating some mentally ill people locally, instead of at large distant special-
ist hospitals.
364 — Antipsychiatry, Deinstitutionalization
the royal commission of 1957
and the mental health act 1959
The Royal Commission on the Law Relating to Mental Illness and
Mental Deficiency, and its legislative sequel, the Mental Health Act of
1959, gave formal recognition to the fundamental change in approach
which was taking place. The Act made far-reaching changes in the pro-
cedures for admission to a mental hospital: for the great majority of
patients, admission for psychiatric treatment now entailed no more
formality than admission for any other form of hospital treatment.
This emphasised the hospital’s role as a place for treatment and not
merely custody. Directions under the National Health Service Act
placed new duties on what were then the health departments of local
authorities to provide for the care and after-care of mentally ill people
outside hospital.

projections of declining numbers of in-patients

By the end of the 1950s the repercussions of the new forms of treatment
were being dramatically reflected in hospital bed numbers. From 3.4 per
1000 population in 1954, the number of occupied beds had already fallen
to 3.1 per 1000 by 1960. Projections made in 1961 by Statisticians at the
General Register Office suggested that in the future some 0.9 beds per
1000 population would be needed for patients staying less than 2 years; and
that a further 0.9 would be required for newly arising longer stay patients.
The projections further suggested that none of the patients then in hospi-
tal would still be there in 15 years or so. The 1962 Hospital Plan recog-
nised the place of the short-stay psychiatric unit as a part of the general
hospital and envisaged that many of the existing mental hospitals would
have no place in the new pattern of service.

the underlying movement to community care

The underlying movement was becoming clearly discernible, namely of
bringing into closer relationship services for the mentally ill whether in
hospital or outside it, with services for other forms of illness and handicap.
Psychiatry was coming in out of the cold. The report of the Royal Com-
mission commented: “The mental health services would lose much more
than they could gain by a return to isolation and separation, and it would
be most unfortunate if schemes for co-ordination between hospitals and
 Better Services for the Mentally Ill — 365
local authorities were not to be accompanied by correspondingly close con-
tact with other parts of their own services.”

how far have expectations been fulfilled?

It is now some 15 years since this watershed. How far have hopes been
fulfilled: how far frustrated and disappointed? The process of integrating
psychiatric with general hospital and community services has gathered
strength. There are now a considerable number of general hospital psy-
chiatric units—although varying considerably in size and adequacy of
accommodation. There is greater emphasis in undergraduate medical edu-
cation on psychiatric illness. Only one of the provincial medical schools
lacks an Academic Department of Psychiatry. There are however still no
such Departments at four of the London medical schools. Social work
support and services for the mentally ill are now an integral part of the
responsibility of local authority social services departments. The process
has not always been smooth. The case, for example, for the integrated
social services departments was hotly debated. Both in the medical and
social work fields those concerned with the mental illness services still
face the very real dilemma of wanting the benefits of integration, yet wish-
ing to retain the different approach to therapy that mental as distinct from
physical illness so often requires; of wanting to be an integral part of the
general pattern of health and social services facilities, but yet wishing to
ensure that the special additional needs of the mentally ill are recognised
and provided for.

physical and non-physical methods of treatment

Drug treatments continue to be widely used, and have played a major part
in facilitating the decline in length of in-patient stay for many patients and
the rapid growth of day and out-patient treatment. It has to be recognised,
however, that research has still not shown the precise mechanism by
which these drugs have their effect. Some argue that drugs are used too
much—particularly in the treatment of neurotic illness; that they treat
symptoms only and ignore the underlying social, psychological, and envi-
ronmental causes of mental illness, for which psychological methods are
more appropriate. In particular some stress the importance of family and
personal relationships as a factor in causing mental illness and argue that
treatment must take account of this. There are those who argue that often
366 — Antipsychiatry, Deinstitutionalization
it is society or the family which is disturbed rather than the individual
patient. Others are equally convinced of the importance of biochemical
factors in causation and argue that from this viewpoint drug treatment is
the logical remedy. The issues are widely discussed and debated; but what
seems beyond doubt is that mental illness is a highly complex phenome-
non, taking many forms and caused by a variety of different factors. In
recognition of this, the great majority of psychiatrists deliberately adopt an
eclectic approach to treatment. While the choice of treatment is a matter
of professional judgment, the patient and his family have to find the choice
acceptable. Although what doctors say to individual patients about their
illness must be a matter for clinical discretion, there would seem to be
much to be said, as a matter of principle, for accepting the need to explain
to the patient and his family the nature of the illness and the doctor’s par-
ticular approach to its treatment.

the “open-door” policy

In one sense there has been very considerable progress towards community
based services, in that the great majority of psychiatric hospitals and units
increasingly see themselves as serving a population that extends far beyond
the hospital walls. Out-patient attendances number 1 1/2 million a year,
day patient attendances 2 million. Psychiatric nurses are working more and
more with patients and their families in their own homes. But by and large
the non-hospital community resources are still minimal, though where
facilities have been developed they have in general proved successful. The
failure, for which central government as much as local government is
responsible, to develop anything approaching adequate social services is
perhaps the greatest disappointment of the last 15 years. As a result the bal-
ance of existing facilities—health and social services—bears increasingly
less relation to acknowledged needs. Hospital staff have, rightly in one
sense, come to see their role as an active therapeutic one and the hospital
as a place for providing medical treatment and nursing care. So they have
become unwilling to act as social care custodians for those who would not
need to remain in hospital were supporting facilities available in the com-
munity. But we have to face the fact that adequate supporting facilities in
the community are not generally available. For many years this will pose a
continuing problem to which there is no easy answer and it places on the
staff of the mental hospitals very real frustrations. Much of their effort in
 Better Services for the Mentally Ill — 367
the past has been directed to developing intensive treatment and rehabilita-
tion leading to discharge back to the community. Largely as a result the
gross overcrowding of earlier years has in general been considerably
reduced. Naturally they wish to see further progress in this direction.
Clearly people should not be admitted to hospital who have no need for
treatment; but admission and discharge policies must be realistic and take
account of the local availability of supporting social services. If they do not,
they put at risk the whole principle of community care in the eyes of the
public. The Government for its part intends to see that over the years the
balance of health and social services is put right.
The frustrations and dilemmas of this situation have been felt no less
by the great majority of local authorities who have been anxious to develop
their services for the mentally ill, but who have been constrained by the
limits on resources and the increasing and competing demands for new
developments throughout the whole social services field.
The term “open-door hospital” has, like “community care” become
with time something of a catchphrase. Such phrases tend to acquire an
oversimplified meaning and it may be worth examining what this concept
means in terms of present day psychiatry. It should clearly be regarded as
signifying an approach to treatment rather than a factual description of the
physical arrangement at the hospital. Wards may be unlocked but profes-
sional judgment needs to be exercised as to whether a particular patient at
a particular time should not be sufficiently supervised at least to prevent his
leaving the hospital and abandoning his treatment. The extent to which
physical security is needed is a separate issue discussed [below], but ade-
quate supervision of the relatively few patients who require it, is important
for public trust and confidence in the overall pattern of care.

From Department of Health and Social Security, Better Services for the Mentally Ill:
Presented to Parliament by the Secretary of State for Social Services by Command of Her
Majesty, October 1975 (London: Her Majesty’s Stationery Office, 1975), 6–9,
11–14.
page 368 is blank.
PART IV

The Psychoboom
In the decades following World War II, the fields of psychiatry,
clinical psychology, and psychotherapy experienced unprece-
dented growth. In the United States, membership in the Ameri-
can Psychological Association grew from 2,739 in 1940, to
30,839 in 1970, to around 75,000 by 1993, while membership
in the American Psychiatric Association rose from 2,423 to
18,407 between 1940 and 1970. A similar trend took place in
Central Europe, where membership in the German Psychologi-
cal Society went from around 2,500 in 1961 to 20,000 in 1984
and more than 40,000 by 1996. These numbers reflect the fact
that, throughout the Western world over the years 1945–2000,
psychiatric, psychometric, and psychotherapeutic ideas, services,
and professionals became commonplace in mainstream society. It
became acceptable among the middle class to see a therapist in
order to deal with interpersonal problems; insurance systems
began to routinely cover the costs of psychotherapy; clinical test-
ing became a prominent part of educational systems; psychiatric
and psychological expertise was frequently called on by govern-
ment to help advise public policy; and newspapers, magazines,
and radio and television outlets recruited counseling profession-
als for advice columns and shows.
The boom in psychiatric, psychological, and psychotherapeu-
tic work represented a shift in orientation, away from custodial
and palliative treatment to outpatient and preventive care. In
short, an emphasis began to be placed on mental health care, as
opposed to simply treating mental illness. Over the course of the
1950s, 1960s, and 1970s, this trend was particularly evident in

369
370 — The Psychoboom

Italy, the Netherlands, Great Britain, West Germany, and the

United States.
The simultaneous expansion of the welfare state and the rise
of mass consumerism had much to do with this. As both the pri-
vate and public service sectors grew, there was a concomitant
growth in the demand for the knowledge and skills of social
workers, nurses, counselors, psychometricians, researchers, and
physicians in mental health care. At the same time, self-help,
encounter, and patient advocacy groups flourished, their leaders
and members taking their cues from consumer and civil rights
movements. This was the period when “patients” became
“clients.”
Attention to the clinical treatment of mental disorders hardly
disappeared, though. Soon after World War II, states and private
firms began investing resources into scientific research, particu-
larly in the area of pharmacology. In the early 1950s, after a
series of experiments, French researchers stumbled upon the
antipsychotic properties of a synthetic drug known as chlorpro-
mazine (marketed as Thorazine). Introduced in American asy-
lums in 1954–1955, the drug produced effects that were
staggering: there were reports that patients who formerly had
been agitated or distracted suddenly became calm and clear-
headed. Within months, chlorpromazine became a standard part
of the treatment regimen in psychiatric hospitals throughout the
United States and Europe. In addition, its implementation
encouraged large pharmaceutical companies to see a lucrative
market in the development of psychiatric drugs. Over the fol-
lowing fifty years, a host of psychotropic medications made their
way into inpatient and outpatient care—amphetamines, barbitu-
rates, benzodiazepines, lithium, MAO inhibitors, tricyclic anti-
depressants.
The increasing reliance of psychiatry—particularly in the
United States—on drug treatment raised questions about stan-
dards and efficacy. How could companies, physicians, govern-
ment officials, and the public be confident that a drug did what
 The Psychoboom — 371

developers claimed? Already in the 1950s, clinical researchers

had begun employing a method used in other disciplines, testing
drug effectiveness by randomly assigning subjects to either an
experimental group receiving treatment or a control group not
receiving the specified treatment. By the 1980s, randomized clin-
ical trials were accepted by many as the final arbiter in deter-
mining the effectiveness of treatments.
Often lost in the popular enthusiasm over drug treatment in
psychiatry is the fact that even the most effective medications
have treated symptoms, not cured diseases. In fact, one of the
questions that rose to prominence during the second half of the
twentieth century was exactly how to single out a set of symp-
toms as constituting a discrete disorder or illness. Contemporary
psychiatric professionals and their organizations have spent a
great deal of time grappling with this thorny problem. It is, how-
ever, only relatively recently that this was even perceived to be a
problem.
Until the twentieth century, there were no universally
accepted standards of diagnosis for mental disorders. Indeed,
historically many physicians believed that a diagnosis was, at
best, largely irrelevant to treating a patient or, at worst, restrict-
ing and deceptive. Over the course of the late nineteenth and
early twentieth centuries, however, governments began
demanding statistical data on insanity. In the United States, the
lack of uniformity in collecting this data led the American
Medico-Psychological Association and the National Committee
for Mental Hygiene in 1918 to issue the first standardized
nosology: the Statistical Manual for the Use of Institutions for the
Insane. During World War II, the U.S. Army and Navy devel-
oped their own classifications, a system that the American Psy-
chiatric Association (APA) adopted and revised after the war,
publishing it as the Diagnostic and Statistical Manual (DSM) in
1952. Heavily inflected by psychoanalytic and psychodynamic
thinking, the manual was revised and published as the DSM-II
beginning in 1968.
372 — The Psychoboom

The content of the DSM has always been closely coordinated

with that found in the World Health Organization’s manual,
the International Classification of Diseases (ICD). And since 1968,
the United States has had a treaty with the World Health Orga-
nization agreeing to accept the ICD as the official diagnostic
manual in the country. Thus, when it was announced that a
ninth revision of the ICD was planned for publication in 1978,
it was decided to once again revise the American DSM. The
result was the DSM-III, a document that represents a major
turning point in the understanding and treatment of mental dis-
orders. Its emphasis on description and behavior and its mar-
ginalization of psychodynamic concepts announced a change in
the governing consensus within psychiatry. From this point on,
biomedical models would come to dominate scholarly and pub-
lic discussions.
 “The Twelve Steps” and “The Twelve Traditions” — 373

Alcoholics Anonymous
(founded 1935)

“The Twelve Steps” and

“The Twelve Traditions”

Concerns over the dominance of professions in psychiatric care

helped to fuel the rise and success of patient advocacy and self-
help groups during the second half of the twentieth century. One
of the most successful and influential self-help organizations has
been Alcoholics Anonymous (A.A.). A.A. arose out of a chance
encounter in 1935 between two self-professed alcoholics: stock-
broker Bill Wilson (known simply as Bill) and surgeon Bob
Smith (known as Dr. Bob). Smith, who had become involved in
the Oxford Group, an organization begun by Christian mission-
ary Frank Buchman, convinced Wilson that overcoming alco-
holism was possible only through turning over one’s life to God.
Working out of Smith’s home in Akron, Ohio, the two men
began helping those struggling with alcohol addiction. They soon
drafted the “Twelve Steps,” and, in 1950, the membership
endorsed a statement of group attitudes and principles crafted by
the founders and early members (the “Twelve Traditions”). By
1951, the organization claimed a U.S. national membership of
one hundred thousand.
A.A.’s twelve-step approach, its regular open meetings, and
its dedication to the principle of anonymity have provided a
model for countless other mental health support groups, such as
Gamblers Anonymous, Narcotics Anonymous, and Overeaters
Anonymous. In 2008, it was estimated that there were more
than 113,000 groups and more than 2 million members in 180
countries.
374 — The Psychoboom
The Twelve Steps

1. We admitted we were powerless over alcohol—that our lives had

become unmanageable.
2. Came to believe that a Power greater than ourselves could restore
us to sanity.
3. Made a decision to turn our will and our lives over to the care of
God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves and to another human being the
exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of
character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to
make amends to them all.
9. Made direct amends to such people wherever possible, except when
to do so would injure them or others.
10. Continued to take personal inventory and when we were wrong
promptly admitted it.
11. Sought through prayer and meditation to improve our conscious
contact with God, as we understood Him, praying only for knowledge
of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we
tried to carry this message to alcoholics, and to practice these prin-
ciples in all our affairs.

The Twelve Traditions

1. Our common welfare should come first; personal recovery depends

upon A.A. unity.
2. For our group purpose there is but one ultimate authority—a lov-
ing God as He may express Himself in our group conscience. Our
leaders are but trusted servants; they do not govern.
3. The only requirement for A.A. membership is a desire to stop
drinking.
 “The Twelve Steps” and “The Twelve Traditions” — 375
4. Each group should be autonomous except in matters affecting other
groups or A.A. as a whole.
5. Each group has but one primary purpose—to carry its message to
the alcoholic who still suffers.
6. An A.A. group ought never endorse, finance or lend the A.A. name
to any related facility or outside enterprise, lest problems of money,
property and prestige divert us from our primary purpose.
7. Every A.A. group ought to be fully self-supporting, declining out-
side contributions.
8. Alcoholics Anonymous should remain forever nonprofessional, but
our service centers may employ special workers.
9. A.A., as such, ought never be organized; but we may create service
boards or committees directly responsible to those they serve.
10. Alcoholics Anonymous has no opinion on outside issues; hence the
A.A. name ought never be drawn into public controversy.
11. Our public relations policy is based on attraction rather than pro-
motion; we need always maintain personal anonymity at the level of
press, radio and films.
12. Anonymity is the spiritual foundation of all our traditions, ever
reminding us to place principles before personalities.

While the Twelve Traditions are not specifically binding on any group or
groups, an overwhelming majority of members have adopted them as the
basis for A.A.’s expanding “internal” and public relationships.

From “The Twelve Steps” and “The Twelve Traditions,” www.aa.org. The Twelve
Steps and Twelve Traditions are reprinted with permission of Alcoholics Anony-
mous World Services, Inc. (“AAWS”). Permission to reprint the Twelve Steps and
Twelve Traditions does not mean that AAWS has reviewed or approved the con-
tents of this publication, or that A.A. necessarily agrees with the views expressed
herein. A.A. is a program of recovery from alcoholism only—use of the Twelve Steps
and Twelve Traditions in connection with other program and activities which are
patterned after A.A., but which address other problems, or in any other non-A.A.
context, does not imply otherwise.
376 — The Psychoboom

Carl Rogers
(1902–1987)

“The Attitude and Orientation

of the Counselor in
Client-Centered Therapy”
(1949)

In two separate surveys of members of the American Psychological

Association conducted in 1982 and 2006, individuals were asked to
identify which psychotherapists most influenced the field and their
own practice. Both times, respondents overwhelmingly agreed on
one name: Carl Rogers. Rogers’s brand of humanistic psychology is
now influencing its third generation of counselors. It is safe to say
that most therapists in the United States today are, in one form or
another, Rogerian.
After first attending seminary, Carl Rogers received his PhD, in
1931, going on to teach at a number of universities in the United
States. Already in the 1940s, Rogers had begun to outline what he
initially called “nondirective” therapy, but later dubbed “client-
centered” or “person-centered” therapy. He eventually moved to
California, where he helped found the Center for Studies of the Per-
son in 1968 and began working closely with encounter groups. The
excerpt here provides a good summary of his therapeutic approach
shortly before publication of his famous book Client-Centered Ther-
apy, published in 1951. It is sometimes easy to forget that, behind
the unassuming tone of his prose, Rogers was directly challenging
psychiatrists and psychoanalysts about the methods they employed.

The Philosophical Orientation of the Counselor

The primary point of importance here is the attitude held by the counselor
toward the worth and the significance of the individual. How do we look
upon others? Do we see each person as having worth and dignity in his
 Rogers, “Client Centered Therapy” — 377
own right? If we do hold this point of view at the verbal level, to what
extent is it operationally evident at the behavioral level? Do we tend to
treat individuals as persons of worth, or do we subtly devaluate them by
our attitudes and behavior? Is our philosophy one in which respect for the
individual is uppermost? Do we respect his capacity and his right to self-
direction or do we basically believe that his life would be best guided by
us? To what extent do we have a need and a desire to dominate others? Are
we willing for the individual to select and choose his own values, or are our
actions guided by the conviction (usually unspoken), that he would be
happiest if he permitted us to select for him his values and standards and
goals?
. . . Perhaps it would summarize the point being made to say that a per-
son can implement, by client-centered techniques, his respect for others
only insofar as that respect is an integral part of his personality makeup;
consequently the person whose operational philosophy has already moved
in this direction of feeling a deep respect for the significance and worth of
each person is more readily able to assimilate the client-centered techniques
which adequately express this feeling.

A Formulation of the Counselor’s Role

At the present stage of thinking in client-centered therapy, there is another

attempt to describe what occurs in the most satisfactory therapeutic rela-
tionships, another attempt to describe the way in which the basic hypoth-
esis is implemented. This formulation would state that it is the counselor’s
function to assume, in so far as he is able, the internal frame of reference of
the client, to perceive the world as the client sees it, to perceive the client
himself as he is seen by himself, and to lay aside all exceptions from the
external frame of reference while doing so. . . .

The Difficulty of Perceiving through the Client’s Eyes

To try to give you, the reader, a somewhat more real and vivid experience
of what is involved in the attitudinal set which we are discussing, it is sug-
gested that you put yourself in the place of the counselor, and consider the
following material, which is taken from complete counselor notes of the
beginning of an interview with a man in his thirties. When the material has
378 — The Psychoboom
been completed, sit back and consider the sorts of attitudes and thoughts
which were in your mind as you read.
Client: I don’t feel very normal, but I want to feel that way. . . . I
thought I’d have something to talk about—then it all goes around in
circles. I was trying to think what I was going to say. Then coming here
it doesn’t work out. . . . I tell you, it seemed that it would be much eas-
ier before I came. I tell you, I just can’t make a decision; I don’t know
what I want. I’ve tried to reason this thing out logically—tried to figure
out which things are important to me. I thought that there are maybe
two things a man might do; he might get married and raise a family. But
if he was just a bachelor, just making a living—that isn’t very good. I
find myself and my thought getting back to the days when I was a kid
and I cry very easily. The dam would break through. I’ve been in the
Army four and a half years. I had no problems then, no hopes, no
wishes. My only thought was to get out when peace would come. My
problems, now that I’m out, are as ever. I tell you, they go back to a long
time before I was in the Army. . . . I love children. When I was in the
Philippines—I tell you, when I was young I swore I’d never forget my
unhappy childhood—so when I saw these children in the Philippines,
I treated them very nicely. I used to give them ice cream cones and
movies. It was just a period—I’d reverted back—and that awakened
some emotions in me I thought I had long buried. (A pause. He seems
very near tears.)
As this material was read, thoughts of the following sorts would repre-
sent an external frame of reference in you, the “counselor.”
I wonder if I should help him get started talking.
Is this inability to get under way a type of dependence?
Why this indecisiveness? What could be its cause?
What is meant by this focus on marriage and family?
He seems to be a bachelor. I hadn’t known that.
The crying, the “dam,” sound as though there must be a great deal
of repression.
He’s a veteran. Could he have been a psychiatric case?
I feel sorry for anybody who spent four and one-half years in the
service.
Some time we will probably need to dig into those early unhappy
experiences.
What is this interest in children? Identification?
Vague homosexuality?
 Rogers, “Client Centered Therapy” — 379
Thoughts which might go through your mind if you were quite suc-
cessful in assuming the client’s internal frame of reference would tend to be
of this order.
You’re wanting to struggle toward normality, aren’t you?
It’s really hard for you to get started.
Decision-making just seems impossible to you.
You want marriage, but it doesn’t seem to you to be much of a
possibility.
You feel yourself brimming over with childish feelings.
To you the Army represented stagnation.
Being very nice to children has somehow had meaning for you.
But it has been—and is—a disturbing experience for you.

If these thoughts are couched in a final and declarative form, then they
shift over into becoming an evaluation from the counselor’s perceptual van-
tage point. But to the extent that they are empathic attempts to understand,
tentative in formulation, then they represent the attitude we are trying to
describe as “adopting the client’s frame of reference.”

The Rationale of the Counselor’s Role

The question may arise in the minds of many, why adopt this peculiar type
of relationship? In what way does it implement the hypothesis from which
we started? What is the rationale of this approach?
In order to have a clear basis for considering these questions, let us
attempt to put first in formal and then in literary terms, a statement of the
counselor’s purpose when he functions in this way. In psychological terms,
it is the counselor’s aim to perceive as sensitively and accurately as possible
all of the perceptual field as it is being experienced by the client, with the
same figure and ground relationships, to the full degree that the client is
willing to communicate that perceptual field; and having thus perceived this
internal frame of reference of the other as completely as possible, to indi-
cate to the client the extent to which he is seeing through the client’s eyes.
Suppose that we attempt a description somewhat more in terms of the
counselor’s attitudes. The counselor says in effect, “To be of assistance to
you I will put aside myself—the self of ordinary interaction—and enter
into your world of perception as completely as I am able. I will become, in
380 — The Psychoboom
a sense, another self for you—a mirror held up to your own attitudes and
feelings—an opportunity for you to discern yourself more clearly, to under-
stand yourself more truly and deeply, to choose more satisfyingly.”

Some Deep Issues

The assumption of the therapeutic role which has been described raises
some very basic questions indeed. An example from a therapeutic inter-
view may pose some of these issues for our consideration. Miss Gil, a
young woman who has shown deep confusion and conflict, and who has
been quite hopeless about herself, has spent the major part of one of her
therapeutic hours discussing her feelings of inadequacy and lack of per-
sonal worth. Part of the time she has been aimlessly using the finger
paints. She has just finished expressing her feelings of wanting to get away
from everyone—to have nothing to do with people. After a long pause
comes the following.

miss g.: I’ve never said this before to anyone—but I’ve thought for such a
long time—This is a terrible thing to say, but if I could just—well,
(short, bitter laugh—pause) If I could just find some glorious cause
that I could give my life for I would be happy. I cannot be the kind of a
person I want to be. I guess maybe I haven’t the guts—or the strength
—to kill myself—and if someone else would relieve me of the responsi-
bility—or I would be in an accident—I—I—just don’t want to live.

c: At the present time things look so black to you that you can’t see
much point in living—

miss g.: Yes—I wish I’d never started this therapy. I was happy when I
was living in my dream world. There I could be the kind of person I
wanted to be—But now—There is such a wide, wide gap—between
my ideal—and what I am. I wish people hated me. I try to make them
hate me. Because then I could turn away from them and could blame
them—but no—It is all in my hands—Here is my life—and I either
accept the fact that I am absolutely worthless—or I fight whatever it is
that holds me in this terrible conflict. And I suppose if I accepted the
fact that I am worthless, then I could go away someplace—and get a
little room someplace—get a mechanical job someplace—and retreat
 Rogers, “Client Centered Therapy” — 381
clear back to the security of my dream world where I could do things,
have clever friends, be a pretty wonderful sort of person—

c: It’s really a tough struggle—digging into this like you are—and at

times the shelter of your dream world looks more attractive and
comfortable.

miss g.: My dream world or suicide.

c: Your dream world or something more permanent than dreams—

miss g.: Yes, (a long pause. Complete change of voice) So I don’t see why
I should waste your time—coming in twice a week—I’m not worth
it—What do you think?

c: It’s up to you, Gil—It isn’t wasting my time—I’d be glad to see you—

whenever you come—but it’s how you feel about it—if you don’t want
to come twice a week—or if you do want to come twice a week?—once
a week?—It’s up to you. (Long pause.)

miss g.: You’re not going to suggest that I come in oftener? You’re not
alarmed and think I ought to come in—every day—until I get out of
this?

c: I believe you are able to make your own decision. I’ll see you whenever
you want to come.

miss g.: (Note of awe in her voice) I don’t believe you are alarmed
about—I see —I may be afraid of myself—but you aren’t afraid for
me—(She stands up—a strange look on her face).

c: You say you may be afraid of yourself—and are wondering why I don’t
seem to be afraid for you?

miss g.: (Another short laugh) You have more confidence in me than I
have. (She cleans up the finger-paint mess and starts out of the room)
I’ll see you next week—(that short laugh) maybe.

Her attitude seemed tense, depressed, bitter, completely beaten. She

walked slowly away.

This excerpt raises sharply the question as to how far the therapist is
going to maintain his central hypothesis. Where life, quite literally, is at
382 — The Psychoboom
stake, what is the best hypothesis upon which to act? Shall his hypothesis
still remain a deep respect for the capacity of the person, or shall he change
his hypothesis? If so what are the alternatives? One would be the hypothe-
sis that “I can be successfully responsible for the life of another.” Still
another is the hypothesis, “I can be temporarily responsible for the life of
another without damaging the capacity for self-determination.” Still
another hypothesis is: “The individual cannot be responsible for himself,
nor can I be responsible for him but it is possible to find someone who can
be responsible for him.”
Does the counselor have the right, professionally or morally, to permit
a client seriously to consider psychosis or suicide as a way out, without
making a positive effort to prevent these choices? Is it a part of our general
social responsibility that we may not tolerate such thinking or such action
on the part of another?
These are deep issues, which strike to the very core of therapy. They
are not issues which one person can decide for another. Different thera-
peutic orientations have acted upon different hypotheses. All that one per-
son can do is to describe his own experience and the evidence which grows
out of that experience.

From Carl Rogers, “The Attitude and Orientation of the Counselor in Client-Cen-
tered Therapy,” Journal of Consulting Psychology 13 (1949): 82–94.

Aaron T. Beck
(b. 1921)

“Cognitive Therapy: Nature and

Relation to Behavior Therapy”
(1970)

The 1960s and 1970s witnessed a renaissance in psychotherapy

that some have argued compares to the revolution of moral therapy
in the eighteenth century. One of the most successful innovations
 Beck, “Cognitive Therapy” — 383
during this time was cognitive-behavioral therapy (CBT). Devel-
oped by Aaron Beck and Albert Ellis (1913–2007) independently of
one another, cognitive-behavioral therapy is likely the most widely
applied form of psychotherapy in the United States today.
Aaron Beck came to the idea of what he originally termed “cogni-
tive therapy” through an early enthusiasm for psychoanalysis. Train-
ing first as an analyst, he carried out experiments that he believed
would demonstrate the accuracy of psychoanalytic theories of
depression. What he found, instead, was that depressed patients
tended to be overwhelmed by spontaneous negative thoughts (“auto-
matic thoughts”) and that challenging the veracity of these thoughts
more often than not led to recovery. In short, contrary to psychoan-
alytic wisdom, it was not necessary to explore deeply into one’s past.
The simplicity and replicability of Beck’s method has made it
amenable to clinical trials and to application for a range of disorders,
including personality disorders, eating disorders, and drug abuse.

Two systems of psychotherapy that have increasingly gained prominence

have been the subject of rapidly increasing number of clinical and experi-
mental studies. Cognitive therapy, the more recent entry into the field of
psychotherapy, and behavior therapy already show signs of becoming
institutionalized.
Although behavior therapy has been publicized in a large number of
articles and monographs, cognitive therapy has received much less recogni-
tion. Despite the fact that behavior therapy is based primarily on learning
theory whereas cognitive therapy is rooted more in cognitive theory, the
two systems of psychotherapy have much in common.
First, in both systems of psychotherapy the therapeutic interview is
more overtly structured and the therapist more active than in other psycho-
therapies. After the preliminary diagnostic interviews in which a systematic
and highly detailed description of the patient’s problems is obtained, both
the cognitive and the behavior therapists formulate the patient’s presenting
symptoms (in cognitive or behavioral terms, respectively) and design spe-
cific sets of operations for the particular problem areas.
After mapping out the areas for therapeutic work, the therapist explic-
itly coaches the patient regarding the kinds of responses and behaviors that
384 — The Psychoboom
are useful with this particular form of therapy. Detailed instructions are pre-
sented to the patient, for example, to stimulate pictorial fantasies (system-
atic desensitization) or to facilitate his awareness and recognition of his
cognitions (cognitive therapy). The goals of these therapies are circum-
scribed, in contrast to the evocative therapies whose goals are open-ended.
Second, both the cognitive and behavior therapists aim their therapeu-
tic technique at the overt symptom or behavioral problem, such as a par-
ticular phobia, obsession, or hysterical symptom. However, the target
differs somewhat. The cognitive therapist focuses more on the ideational
content involved in the symptom, viz., the irrational inferences and prem-
ises. The behavior therapist focuses more on the overt behavior, e.g., the
maladaptive avoidance responses. Both psychotherapeutic systems concep-
tualize symptom formation in terms of constructs that are accessible either
to behavioral observation or to introspection, in contrast to psychoanalysis,
which views most symptoms as the disguised derivatives of unconscious
conflicts.
Third, in further contrast to psychoanalytic therapy, neither cognitive
therapy nor behavior therapy draws substantially on recollections or re-
constructions of the patient’s childhood experiences and early family
relationships. The emphasis on correlating present problems with develop-
mental events, furthermore, is much less prominent than in psychoanalytic
psychotherapy.
A fourth point in common between these two systems is that their the-
oretical paradigms exclude many traditional psychoanalytic assumptions
such as infantile sexuality, fixations, the unconscious, and mechanisms of
defense. The behavior and cognitive therapists may devise their therapeutic
strategies on the basis of introspective data provided by the patient; how-
ever, they generally take the patients’ self-report at face value and do not
make the kind of high-level abstractions characteristic of psychoanalytic
formulations.
Finally, a major assumption of both cognitive therapy and behavior
therapy is that the patient has acquired maladaptive reaction patterns that
can be “unlearned” without the absolute requirement that he obtain
insight into the origin of the symptom. . . .
The most striking theoretical difference between cognitive and behav-
ior therapy lies in the concept used to explain the dissolution of maladap-
tive responses through therapy. Wolpe, for example, utilizes behavioral or
 Beck, “Cognitive Therapy” — 385
neurophysiological explanations such as counter-conditioning or reciprocal
inhibition; the cognitivists postulate the modification of conceptual sys-
tems, i.e., changes in attitudes or modes of thinking. As will be discussed
later, many behavior therapists implicitly or explicitly recognize the impor-
tance of cognitive factors in therapy, although they do not expand on these
in detail.

Techniques of Cognitive Therapy

Cognitive therapy may be defined in two ways: In a broad sense, any tech-
nique whose major mode of action is the modification of faulty patterns of
thinking can be regarded as cognitive therapy. This definition embraces all
therapeutic operations that indirectly affect the cognitive patterns, as well as
those that directly affect them. An individual’s distorted views of himself
and his world, for example may be corrected through insight into the his-
torical antecedents of his misinterpretations (as in dynamic psychother-
apy), through greater congruence between the concept of the self and the
ideal (as in Rogerian therapy), and through increasingly sharp recognition
of the unreality of fears (as in systematic desensitization).
However, cognitive therapy may be defined more narrowly as a set of
operations focused on a patient’s cognitions (verbal or pictorial) and on the
premises, assumptions, and attitudes underlying these cognitions. This
section will describe the specific technique of cognitive therapy.

recognizing idiosyncratic cognitions

One of the main cognitive techniques consists of training the patient to rec-
ognize his idiosyncratic cognitions or “automatic thoughts” (Beck, 1963).*
Ellis (1962) refers to these cognitions as “internalized statements” or “self-
statements,” and explains them to the patient as “things that you tell your-
self.” † These cognitions are termed idiosyncratic because they reflect a
faulty appraisal, ranging from a mild distortion to a complete misinterpre-
tation, and because they fall into a pattern that is peculiar to a given indi-
vidual or to a particular psychopathological state.

*Author’s note: A. T. Beck, “Thinking and Depression: 1. Idiosyncratic Content

and Cognitive Distortions,” Archives of General Psychiatry 9 (1963): 324–333.
†
Author’s note: A. Ellis, Reason and Emotion in Psychotherapy (New York: Lyle Stu-
art, 1962).
386 — The Psychoboom
In the acutely disturbed patient, the distorted ideation is frequently in
the center of the patient’s phenomenal field. In such cases, the patient is
very much aware of these idiosyncratic thoughts and can easily describe
them. The acutely paranoid patient, for instance, is bombarded with
thoughts relevant to his being persecuted, abused, or discriminated against
by other people. In the mild or moderate neurotic, the distorted ideas are
generally at the periphery of awareness. It is therefore necessary to motivate
and to train the patient to attend to these thoughts.
Many patients reporting unpleasant affects describe a sequence con-
sisting of a specific event (external stimulus) leading to an unpleasant affect.
For instance, the patient may outline the sequence of (a) seeing an old
friend and then (b) experiencing feelings of sadness. Oftentimes, the sad-
ness is inexplicable to the patient. Another person (a) hears about some-
one having been killed in an automobile accident and (b) feels anxiety.
However, he cannot make a direct connection between these two phenom-
ena; e.g., there is a missing link in the sequence.
In these instances of a particular event leading to an unpleasant affect,
it is possible to discern an intervening variable, namely, a cognition, which
forms the bridge between the external stimulus and the subjective feeling.
Seeing an old friend stimulates cognitions such as “It won’t be like old
times,” or “He won’t accept me as he used to.” The cognition then gener-
ates sadness. The report of the automobile accident stimulates a pictorial
image in which the patient himself is the victim of an automobile accident.
The image then leads to anxiety.
This paradigm can be further illustrated by a number of examples. A
patient treated by the writer complained that he experienced anxiety when-
ever he saw a dog. He was puzzled by the fact that he experienced anxiety
even when the dog was chained or caged or else was obviously harmless.
The patient was instructed: “Notice what thoughts go through your mind
the next time you see a dog—any dog.” At the next interview, the patient
reported that during numerous encounters with dogs between appoint-
ments, he had recognized a phenomenon that he had not noticed previ-
ously; namely, that each time he saw the dog he had a thought such as “It’s
going to bite me.”
By being able to detect the intervening cognitions, the patient was able
to understand why he felt anxious, namely, he indiscriminately regarded
every dog as dangerous. He stated, “I even got that thought when I saw a
 Beck, “Cognitive Therapy” — 387
small poodle. Then I realized how ridiculous it was to think that a poodle
could hurt me.” He also recognized that when he saw a big dog on a leash,
he thought of the most deleterious consequences: “The dog will jump up
and bite out my eyes,” or “It will jump and bite my jugular vein and kill
me.” Within 2 or 3 weeks, the patient was able to overcome completely his
long-standing dog phobia simply by recognizing his cognitions when
exposed to a dog.
Another example was provided by a college student who experienced
inexplicable anxiety in a social situation. After being trained to examine
and write down his cognitions, he reported that in social situations he
would have thoughts such as, “They think I look pathetic,” or “Nobody
will want to talk to me,” or “I’m just a misfit.” These thoughts were fol-
lowed by anxiety. . . .
Sometimes, the cognition may take a pictorial form instead of, or in
addition to, the verbal form. A woman who experienced spurts of anxiety
when riding across a bridge was able to recognize that the anxiety was pre-
ceded by a pictorial image of her car breaking through the guard rail and
falling off the bridge. Another woman, with a fear of walking alone, found
that her spells of anxiety followed images of her having a heart attack and
being left helpless and dying on the street. A college student discovered that
his anxiety at leaving his dormitory at night was triggered by visual fan-
tasies of being attacked.
The idiosyncratic cognitions (whether pictorial or verbal) are very
rapid and often may contain an elaborate idea compressed into a very short
period of time, even into a split second. These cognitions are experienced
as though they are automatic; i.e., they seem to arise as if by reflex rather
than through reasoning or deliberation. They also seem to have an invol-
untary quality. A severely anxious or depressed or paranoid person, for
example, may continually experience the idiosyncratic cognitions, even
though he may try to ward them off. Furthermore, these cognitions tend to
appear completely plausible to the patient.

distancing
Even after a patient has learned to identify his idiosyncratic ideas, he may
have difficulty in examining these ideas objectively. The thought often
has the same kind of salience as the perception of an external stimulus.
“Distancing” refers to the process of gaining objectivity towards these
388 — The Psychoboom
cognitions. Since the individual with a neurosis tends to accept the validity
of his idiosyncratic thoughts without subjecting them to any kind of criti-
cal evaluation, it is essential to train him to make a distinction between
thought and external reality, between hypothesis and fact. Patients are often
surprised to discover that they have been equating an inference with reality
and that they have attached a high degree of truth-value to their distorted
concepts.
The therapeutic dictum communicated to the patient is as follows: Sim-
ply because he thinks something does not necessarily mean that it is true.
While such a dictum may seem to be a platitude, the writer has found with
surprising regularity that patients have benefited from the repeated
reminder that thoughts are not equivalent to external reality.
Once the patient is able to “objectify” his thoughts, he is ready for the
later stages of reality testing: applying rules of evidence and logic and con-
sidering alternative explanations.

correcting cognitive distortions and deficiencies

The writer has already indicated that patients show faulty or disordered
thinking in certain circumscribed areas of experience. In these particular
sectors, they have a reduced ability to make fine discriminations and tend
to make global, undifferentiated judgments. Part of the task of cognitive
therapy is to help to recognize faulty thinking and to make appropriate cor-
rections. It is often very useful for the patient to specify the kind of falla-
cious thinking involved in his cognitive responses.
Arbitrary inference refers to the process of drawing a conclusion when
evidence is lacking or is actually contrary to the conclusion. This type of
deviant thinking usually takes the form of personalization (or self-refer-
ence). A depressed patient, who saw a frown on the face of a passerby,
thought, “He is disgusted with me.” A phobic girl of 21, reading about
a woman who had a heart attack, got the thought, “I probably have heart
disease.” A depressed woman, who was kept waiting for a few minutes
by the therapist, though, “He has deliberately left in order to avoid see-
ing me.”
Overgeneralization refers to the process of making an unjustified gener-
alization on the basis of a single incident. This may take the form that was
described in the case of the man with the dog phobia, who generalized from
a particular dog that might attack him to all dogs. Another example is the
 Beck, “Cognitive Therapy” — 389
patient who thinks, “I never succeeded at anything,” when he has a single
isolated failure.
Magnification refers to the propensity to exaggerate the meaning or sig-
nificance of a particular event. A person with a fear of dying, for instance,
interpreted every unpleasant sensation or pain in his body as a sign of some
fatal disease such as cancer, heart attack, or cerebral hemorrhage. Ellis
(1962) applied the label “catastrophizing” to this kind of reaction. . . .
Cognitive deficiency refers to the disregard for an important aspect of a
life situation. Patients with this defect ignore, fail to integrate, or do not uti-
lize information derived from experience. Such a patient, consequently,
behaves as though he has a defect in this system of expectations: He con-
sistently engages in behavior which he realizes, in retrospect, is self-defeat-
ing. This class of patients includes those who “act out,” e.g., psychopaths,
as well as those whose overt behavior sabotages important personal goals.
These individuals sacrifice long-range satisfaction or expose themselves to
later pain or danger in favor of immediate satisfactions. This category
includes problems such as alcoholism, obesity, drug addiction, sexual devi-
ation, and compulsion gambling. . . .
Therapy of such cases consists of training the patient to think of the
consequences as soon as his self-defeating wish arises. Consideration of the
long-range loss must be forced into the interval between impulse and
action. A patient, for instance, who continually operated his car beyond the
speed limit or drove thorough stoplights was surprised each time he was
stopped by a traffic officer. On interview, it was discovered that the patient
was generally absorbed in a fantasy while driving—he imagined himself as
a famous racing-car driver engaged in a race. Therapy at first consisted of
trying to get him to watch the odometer—but without success. The next
approach consisted of inducing fantasies of speeding, getting caught, and
receiving punishment. At first, the patient had great difficulty in visualizing
getting caught even though, in general, he could fantasize almost every-
thing. However, after several sessions of induced fantasies, he was able to
incorporate a negative outcome into his fantasy. Subsequently, he stopped
daydreaming while driving and was able to observe traffic regulations.
In the following case report,* several cognitive techniques directed at
modifying anxiety proneness are illustrated.

*Author’s note: This patient was treated in collaboration with Dr. William Dyson.
390 — The Psychoboom
Case Report

Mrs. G. was an attractive 27-year-old mother of three children. When first

seen by the writer, she complained of periods of anxiety lasting up to 6 or
7 hr a day and recurring repeatedly over a 4-year period. She had consulted
her family physician, who had prescribed a variety of sedatives, including
Thorazine, without any apparent improvement.
In an analysis of the cause-and-effect sequence of her anxiety, the fol-
lowing facts were elicited. The first anxiety episode occurred about 2 weeks
after she had a miscarriage. At that time she was bending over to bathe her
1-year-old son, and she suddenly began to feel faint. Following this episode,
she had her first anxiety attack which lasted several hours. The patient
could not find any explanation for her anxiety. However, when the writer
asked whether she had had any thought at the time she felt dizzy, she
recalled having had the thought, “Suppose I should pass out and injure the
baby.” It seemed plausible that her dizziness, which was probably the result
of postpartum anemia, led to the fear she might faint and drop the baby.
This fear then produced anxiety, which she interpreted as a sign that she
was “going to pieces.”
Until the time of her miscarriage, the patient had been reasonably care-
free and had not experienced episodes of anxiety. However, after her mis-
carriage, she periodically had the thought, “Bad things can happen to me.”
Subsequently, when she heard of somebody’s becoming sick, she often
would have the thought, “This can happen to me,” and she would being to
feel anxious.
The patient was instructed to try to pinpoint any thoughts that pre-
ceded further episodes of anxiety. At the next interview, she reported the
following events:
1. One evening, she heard that the husband of one of her friends was
sick with a severe pulmonary infection. She then had an anxiety attack last-
ing several hours. In accordance with the instructions, she tried to recall
the preceding cognition, which was, “Tom could get sick like that and
maybe die.”
2. She had considerable anxiety just before starting a trip to her
sister’s house. She focused on her thoughts and realized she had the
repetitive thought that she might get sick on the trip. She had had a
serious episode of gastroenteritis during a previous trip to her sister’s
 Beck, “Cognitive Therapy” — 391
house. She evidently believed that such a sickness could happen to her
again.
3. On another occasion, she was feeling uneasy and objects seemed
somewhat unreal to her. She then had the thought that she might be
losing her mind and immediately experienced an anxiety attack.
4. One of her friends was committed to a state hospital because of a
psychiatric illness. The patient had the thought, “This could happen to
me. I could lose my mind.” When questioned about why she was afraid of
losing her mind, she stated that she was afraid that if she went crazy, she
would do something that would harm either her children or herself.
It was evident that the patient’s crucial fear was the anticipation of loss
of control, whether by fainting or by becoming psychotic. The patient was
reassured that there were no signs that she was going psychotic. She was
also provided with an explanation of the arousal of her anxiety and of her
secondary elaboration of the meaning of these attacks.
The major therapeutic thrust in this case was coaching the patient to
recall and reflect on the thoughts that preceded her anxiety attacks. The
realization that these attacks were initiated by a cognition rather than by
some vague mysterious force convinced her she was neither totally vulner-
able nor unable to control her reactions. Furthermore, by learning to pin-
point the anxiety-reducing thoughts, she was able to gain some detachment
and to subject them to reality testing. Consequently, she was able to nullify
the effects of those thoughts. During the next few weeks, her anxiety
became less frequent and less intense and, by the end of 4 weeks, they dis-
appeared completely.

Aaron T. Beck, “Cognitive Therapy: Nature and Relation to Behavior Therapy,”

Behavior Therapy 1 (1970): 184–200. Copyright Elsevier 1970.
392 — The Psychoboom

Edna I. Rawlings and

Dianne K. Carter
“The Intractable Female Patient”
(1977)

Among the postwar social movements that had a direct impact on

psychiatry and psychotherapy, the women’s movement was among
the most important. Dating back to ancient times, girls and women
were singled out as being uniquely predisposed to madness and
mental illness. At the same time, men dominated the ranks of med-
icine, the church, government, and academia and, thus, had a dis-
proportionately greater say in how mental maladies were perceived
and treated. The emergence of a new range of social and political
possibilities for women, combined with the expanded role of social
workers and nurses within social psychiatry, provided women with
the opportunity to assume a more directive position in mental
health care.
Edna Rawlings and Dianne Carter became involved in a con-
sciousness-raising group at the University of Iowa in the 1970s.
This experience led them to begin exploring how feminism could
contribute to critically rethinking psychotherapy. In 1977, they
published the influential book Psychotherapy for Women, in which
they argued, among other things, that the chief sources of women’s
pathology were not personal and internal, but social and external,
and that women should not be encouraged to adjust themselves to
the unequal social conditions in which they lived. In the following
excerpt, the authors critically examine a case history they consid-
ered emblematic of the kinds of chauvinistic thinking present in
mental health care at the time.

The published case history appeared in the American Journal of Psychiatry,

129:1, July 1972, under the title, “The Intractable Female Patient.” It was
 Rawlings & Carter, “The Intractable Female Patient” — 393
written by H. Houck, M.D., Medical Director of the Institute of Living in
Hartford, Connecticut.*
In using the phrase, “intractable female patient,” Dr. Houck referred to
a category of female patients with similar syndromes, histories, and courses
of “illness.” “Intractable,” according to Houck, means that the patient is
not easily governed, managed or controlled. The “illness” exhibited by
these women is, therefore, difficult to relieve or cure. This intractability
which leads to hospitalization actually appears long before the hospitaliza-
tion is necessary. Although these patients may have a variety of diagnoses,
Houck classifies them all under the category of borderline syndrome
described by Grinker.†
The patient’s presenting problems include anxiety and depression;
chronic depression, characterized by anhedonia, is the most prominent fea-
ture. However, the patient may not describe herself as depressed, even
though she looks and acts unhappy.

Although they are often attractive, most of these women are socially
awkward, sexually naïve, and inhibited (p. 27) . . . She is immature, anx-
ious, and angry, usually aloof, and contemptuous of other women, and
demanding and suspicious of men (p. 28).

The early history of the patient reveals poor family relationships. Her
mother was probably cold, aloof and dominating; her father, passive and
withdrawn. Her husband “tends to be like the father; passive, variably
indulent [sic], and easily dominated” (p. 27). Sexual adjustment of the

*Authors’ note: We asked Dr. Houck’s permission to publish his case history ver-
batim in this book; however, after we sent him material outlining the chapter in
which his article would appear, he rescinded permission. He [sic] stated reasons were
that our treatment would distort what he intended to say and that he did not wish
to be placed, by implication, in either a profeminist or an antifeminist position. The
reader will, therefore, have to rely on our summary of Dr. Houck’s analysis. We rec-
ommend that the reader obtain Dr. Houck’s original paper, both to form his/her
own opinion of the case and to experience the full impact of Dr. Houck’s approach.
†
Authors’ note: The borderline is a syndrome characteristic of arrested develop-
ment of ego-functions. Some of the symptoms noted are: anger as the main affect, a
deficiency in affectional relationships, depressive loneliness, and the apparent
absence of self-identity. Although the borderline syndrome appears to be a confus-
ing combination of psychotic, neurotic, and character disturbances with many nor-
mal elements, the process itself has a considerable degree of internal consistency
and stability and is not merely a response to situational stress (Grinker, Werble, &
Drye, 1968).
394 — The Psychoboom
patient and her husband has always been poor. Child-rearing appears to be
the stress that precipitated her hospitalization.
Soon after hospitalization the patient shows remarkable improve-
ment. Houck attributes the improvement to secondary gains obtained by
the patient in the form of relief from the demands of home and family.
Labeling herself as “sick” legitimizes the patient’s escape from her life’s
responsibilities.
The hospital therapist, particularly a young resident, will immediately
judge the patient as an excellent candidate for psychotherapy because, as
Houck describes her, she is

young, intelligent, articulate, psychiatrically sophisticated, well moti-

vated . . . She is, in short, exactly the kind of patient with whom the
young resident in particular hopes to work (p. 27).

The resident and the patient quickly generate a lot of relevant case his-
tory material. The initial treatment plan includes intensive psychotherapy
and, secondarily, some tranquilizing medicine. The patient rapidly develops
a dependence on the therapist. Auspiciously, the therapist interprets this as
transference.
Soon after therapy begins, a treatment crisis arises. The patient’s
depression and anxiety return without any apparent precipitating cause.
Reassurances from the therapist and increases in medication merely exac-
erbate the problem. On the other hand, firm limits and control by the ther-
apist lead to improvement. The patient’s hostility diminishes, she becomes
penitent, and improves. The young therapist may misinterpret the crisis
and recovery as a turning point in therapy; however, similar crises continue
to occur. The patient uses considerable guile and cunning to undercut the
therapist’s authority. She appears to derive pleasure from her ability to con-
trol therapy by producing a stalemate. In the face of repeated discourage-
ment, the therapist who is committed to psychotherapy, refuses to
recognize that the patient is not making progress.
In spite of lack of progress, the husband seldom questions the hospital
regarding treatment. He is actually more comfortable with his wife out of
the home and he is, as noted above, a very passive person. In cases in which
the husband does intervene by removing his wife from the hospital or by
threatening divorce, the wife, faced with external conditions over which she
has no control, may actually improve. Houck attributes improvement in
 Rawlings & Carter, “The Intractable Female Patient” — 395
this instance to the efficacy of environmental manipulation over intensive
psychotherapy for this type of patient.
In contrast to the young therapist’s treatment, Houck recommends
short hospital stays without intensive psychotherapy and without encour-
agement of childlike dependence or regressive behavior.

The patient’s hospital stay must be comparatively brief, her therapy

supportive and aggressively reality oriented, and her attention firmly
fixed on home, family, and adult obligations. . . . The pressure through-
out the whole of the hospital milieu moves ever toward control, matu-
rity, and independence (p. 30).

In addition, Houck suggest that the therapist concentrate his effort on

the husband to assist him in modifying

lifelong attitudes of passivity and diffidence and to assume a posture of

strength and resolution—especially toward his wife (p. 30).

The patient will, of course, be ambivalent about the personality changes

occurring in her husband and she will use the ploys to test and undermine
his dominance and control similar to those she used with her therapist.
She will not be happy to leave the hospital and return to the home; fam-
ily stress may result in a return to the hospital. Again, the duration of hos-
pitalization must be limited at the onset. Eventually it may be necessary to
block hospitalization as an avenue of escaping her duties as wife and
mother. Houck claims that the patient will not make progress until she
exerts great pressures on the husband, testing him to take control:

She will test him to the limit, but if he passes the test she is reassured
and comforted. She will keep trying, but she is often aware, at last, that
she really hopes she will not win (p. 31).

In the following comparative case analysis, Houck’s conception of the prob-

lem, his values as a therapist and his approach to treatment will be con-
trasted with those of feminist therapists. Naturally, we cannot speak for all
feminist therapists; thus the ideas expressed in the right-hand column rep-
resent our own views as feminist therapists. The concepts listed in the left-
hand column represent our understanding or interpretation of what Dr.
Houck has said in his article; we also assume full responsibility for that
interpretation.
396 — The Psychoboom
Dr. Houck’s Therapy Feminist Therapy
Conception of the Problem Conception of the Problem
Terms such as “illness” and All the problems described in the
“disease” are used in describing paper are of a behavioral nature.
the patient. The patient has “problems” in
living (Szasz 1971).
“Intractable” means that the patient If the patient were male, such traits
is obstinate toward change and is would be considered evidence of
not easily dominated. She has a a well-integrated ego. Feminist
strong will and she is not willing therapists consider such traits to
to be governed. In a woman these be healthy for people.
traits are evidence of pathology.
Her principal symptoms include If the patient is suffering from
depression and anhedonia. chronic depression, it seems that
she is not sufficiently intractable for
her own survival. Her intractibility
could be interpreted as a positive
sign that she is fighting against
being submerged as an individual.
The patient does not describe If the patient is depressed without
herself as depressed; however, awareness, she is out of touch with
she looks and acts depressed. herself and her feelings; she may
be attempting to suppress aspects
of herself that are even more
unacceptable to others than her
present behavior.
The patient is hospitalized because The patient is hospitalized because
she refuses to meet her adult of the failure of the traditional
responsibilities to her home and feminine sex role. As Bernard
family. (1971) noted: “In truth, being a
housewife makes women sick.”
Since the patient and others in her
environment (including her
therapists) think that performing
the feminine role is the only
acceptable behavior for a woman,
one of the patient’s few alternatives
is to “go crazy.”
Soon after hospitalization the The patient has indeed escaped
patient improved remarkably. from the intolerable life situation—
This suggests that her hospital- one that produced considerable
ization is providing her with stress for her. We view her behavior
 Rawlings & Carter, “The Intractable Female Patient” — 397
secondary gains in the form of diagnostically, rather than morally,
escaping from her home and family. giving us clues to the nature of her
Thus, her behavior is viewed from conflict.
a moral perspective (shirking her
responsibilities).
The patient’s mother is described We agree that the patient may be
as cold, aloof, and domineering. having difficulty in adapting to the
Her father is described as passive traditional feminine sex-role.
and withdrawn. Her husband is We also believe that the patient’s
also described as “passive, variably important people, as described,
indulgent and easily dominated.” would not provide effective role
In presenting these descriptions of models for anyone, male or female.
significant others in the patient’s
environment, Houck implies that
the root of her difficulties is a lack
of adequate sex-role models.
The patient is described as Houck’s description fits the
attractive but “socially awkward, traditional female in our society.
sexually naïve and inhibited.” Appearance, sociability, and
sexuality are the dimensions
on which women are judged.
Other dimensions are assumed
to be essentially irrelevant.
The patient is described as “young, The patient fits Goldstein’s (1972)
intelligent, articulate, psychiatrically description of the ideal patient:
sophisticated and well-motivated.” YAVIS (young, attractive, verbal,
She is mistakenly viewed as an ideal intelligent, sophisticated). This
candidate for intensive description suggests that she not
psychotherapy. only is an ideal patient but also
has considerable personal strengths
to draw upon in spite of the
pathonomic diagnostic labels she
receives from psychiatrists.
The patient is described as According to our diagnostic
immature. Note: “Immature” is formulation the patient does not
a vague term which is not defined have an adequate sense of her own
in the text. We assume from the personhood, even though she dares
context that Houck means the to struggle to define herself in the
patient does not have an adequate face of strong social and therapist
(traditional) sex-role identification, disapproval.
i.e. she does not do her housework
or take care of her children.
She also has the audacity to
challenge the therapist’s authority.
398 — The Psychoboom
Houck also describes the patient In our culture women are trained in
as contemptuous of women and these behaviors and in turn are
suspicious of men. labeled pathological by therapists
for exhibiting them.
The patient allegedly yearns for Wanting affection seems to us a
affection and dominance. normal human desire. Wanting to
be dominated is the interpretation
of a male psychiatrist based upon
beliefs concerning appropriate
behavior of a woman. We agree that
the patient exhibits conflict over the
issue of dominance, vacillating
between dependency and attempts
to assert herself. A basic theme that
emerges in this case is one of
control: whether the patient will be
allowed to decide the course of her
life or whether others (therapist or
husband) will direct her life.
Houck insists that the core of the We agree, but view her anger as
patient’s syndrome is anger. appropriate and healthy. Using sex-
role analysis, a feminist therapist
could assist the patient in articu-
lating the basis of her anger and
channeling it in constructive ways.
The sexual adjustment of this Why attribute the sexual difficulties
patient is difficult and unsatisfying. to the patient? Masters and Johnson
(1970) attribute 50 percent of any
sexual problem to the wife and
50 percent to the husband. Since
we know that the interpersonal
relationship between this couple
is unsatisfactory, we would be
surprised if they reported a
satisfactory sexual relationship.
Bardwick (1973) observed that the
“normal” woman usually engages in
coitus not to gratify her own genital
sexuality but to satisfy her male
partner’s needs and to secure his
love. Reduced to using sex as barter
for affection, this woman, along
with many other women, does not
derive physical pleasure from sex.
 Rawlings & Carter, “The Intractable Female Patient” — 399
Treatment Goals Treatment Goals
Therapy is to be reality oriented; Therapy will include sex-role
i.e. the patient should be analysis. The therapist will show
encouraged to assume her adult the woman how the traditional role
obligations of housework and expectations for women are related
motherhood. In sum, the patient to her present conflicts. She will be
should achieve an adequate encouraged to neutralize the effect
feminine identity. The focus of of others’ expectations upon her to
treatment should be toward decide what she wants for herself,
independence and maturity. and to take charge of her life to
Note: These words are attain her goals. Feminists would
operationally defined by Houck. not disagree with the goals of
He implies that an independent, independence and maturity, but
mature woman carries out her would define them in a different
adult obligations as stated above. way. “Independence” implies that a
woman has achieved a separate
personhood, i.e. she has a sense of
identity beyond that of wife,
mother, and daughter. She also
should have the means to be
economically independent if she so
chooses. “Maturity” means that she
takes responsibility for the direction
of her life and is capable of working
in a persistent fashion toward
achieving her goals.
The husband should be helped Feminists oppose the traditional
to become dominant in the heterosexual relationship model
relationship and to control his wife of male dominance and female
who should be submissive and submission. Healthy relationships
dependent in the relationship. are based on equality between the
persons involved. A basic
inconsistency in the feminine role
is that women are expected to be
competent and strong, except when
they are relating to men. The wife
cannot achieve independence and
maturity if significant males
(therapists and husbands) are
constantly blocking and punishing
her self-assertive responses. Both
the husband and wife described in
this case history would probably
benefit from assertion training to
learn how to assert their needs in
an appropriate manner.
400 — The Psychoboom
Style of Treatment Style of Treatment
Authoritarian. The therapist is Egalitarian. The therapist and
expected to be in control of the woman client will enter into a
patient who is ideally cooperative therapy contract agreeing on the
and docile. The therapist sets the goals of treatment. Feminist
goals of treatment and uses his therapists assume that a woman can
influence over the patient and her accurately report her own reality.
environment to see that his goals If the therapist observes discrep-
are achieved. The therapist is ancies in a woman’s behavior or
cautioned by Houck to set limits between her behaviors and therapy
and to exert firm control. goals s/he will point out these
discrepancies as the therapist’s
perception, not as reality.

Recommended Treatment Recommended Treatment

Approach Approach

Environmental manipulation. Limited Environmental analysis including

stays in the hospital, training the sex-role analysis. This recommended
husband to be more dominant in approach would neutralize the
the relationship, and blocking patient’s feeling “crazy.” Any
future hospitalizations in order to environmental changes that she
prevent the patient from escaping decides to make after careful
her responsibilities as a wife and examination of the consequences,
mother are the treatment including divorce or reconciliation
recommendations. with husband, are respected by the
therapist.
The patient’s attempts to control The therapist and woman enter into
and manipulate the therapist are to a treatment contract which includes
be avoided. Note: This suggests mutually agreed on goals and ways
suspicion and mistrust of her of achieving them. This reduces the
motives. possibility of manipulation by either
party.
Houck opposes intensive individual Feminist therapists prefer to work
psychotherapy. Presumably in group therapy. A group of
individual therapy will prolong women who have faced similar
treatment and collude with the problems provide support and
patient’s attempts to evade her confirmation of the patient’s reality.
responsibilities to her husband A group will not allow her to evade
and children. her responsibilities to herself. The
therapeutic contract and feedback
from the group will prevent the
therapist or the woman from
prolonging treatment.
 “Post-traumatic Stress Disorder” — 401
Implied Values Explicit Values
Acceptance of marriage as the only Traditional marriage based on the
acceptable life-style for women. dominance-submission model is
oppressive to women; healthy
relationships are based on equality.
Many life-styles are acceptable for
women.
A woman can be fulfilled only as a Unless a woman is fulfilled as a
wife and mother. person she cannot be fulfilled as a
wife and mother.
A woman’s mental health depends A woman’s mental health depends
on her being submissive and having on her having personal power—
a dominant husband. being effective in controlling her
own life.

From Edna I. Rawlings and Dianne K. Carter, “The Intractable Female Patient,” in
Psychotherapy for Women: Treatment toward Equality, 1st ed. (Springfield, IL, 1977),
77–86. Courtesy of Charles C. Thomas Publisher, Ltd., Springfield, Illinois.

Diagnostic and Statistical Manual

of Mental Disorders-III
“Post-traumatic Stress Disorder”
(1980)

In 1974, the American Psychiatric Association formed a task force

to coordinate changes in standardized diagnoses in order to keep up
with impending revisions of the World Health Organization’s Inter-
national Classification of Diseases (ICD). The DSM-III, published in
1980, marked a watershed in American and world psychiatry. Influ-
enced by the apparent success of new medications on certain psy-
chiatric disorders and a desire to scientifically demonstrate the
effectiveness of categories and treatments in economically trying
times, the framers of the DSM-III moved away from etiological
402 — The Psychoboom
explanations and psychodynamic vocabulary to stress behavior. The
DSM-III quickly became indispensable, in that, for the first time, it
created a widely accepted, uniform standard for research, publica-
tion, funding, and insurance purposes.
The diagnosis of post-traumatic stress disorder (PTSD) was one
of the DSM-III’s innovations. Inspiration for it was drawn from ear-
lier diagnoses such as “traumatic neurosis” and “shell shock” and
was influenced by demands for recognition from Vietnam War vet-
erans and their supporters. In the end, the DSM-III framers crafted
a diagnosis that proved to be controversial, particularly in the 1980s
and 1990s, raising a number of difficult questions. Can memories
be traumatic? Can they be repressed? Can repressed memories be
reliably recovered? What is the difference between causes of and
reasons for a mental illness? And how does one distinguish between
a set of symptoms and a disease?

Post-traumatic Stress Disorder, Chronic or Delayed

The essential feature is the development of characteristic symptoms fol-

lowing a psychologically traumatic event that is generally outside the range
of usual human experience.
The characteristic symptoms involve reexperiencing the traumatic
event; numbing of responsiveness to, or reduced involvement with, the
external world; and a variety of autonomic, dysphoric, or cognitive
symptoms.
The stressor producing this syndrome would evoke significant symp-
toms of distress in most people, and is generally outside the range of such
common experiences as simple bereavement, chronic illness, business
losses, or marital conflict. The trauma may be experienced alone (rape or
assault) or in the company of groups of people (military combat). Stres-
sors producing this disorder include natural disasters (floods, earth-
quakes), accidental man-made disasters (car accidents with serious
physical injury, airplane crashes, large fires), or deliberate man-made disas-
ters (bombing, torture, death camps). Some stressors produce the dis-
order (e.g., torture) and others produce it only occasionally (e.g., car
 “Post-traumatic Stress Disorder” — 403
accidents). Frequently there is a concomitant physical component to the
trauma which may even involve direct damage to the central nervous sys-
tem (e.g., malnutrition, head trauma). The disorder is apparently more
severe and longer lasting when the stressor is of human design. The sever-
ity of the stressor should be recorded and the specific stressor may be
noted on Axis IV.
The traumatic event can be reexperienced in a variety of ways. Com-
monly the individual has recurrent painful, intrusive recollections of the
event or recurrent dreams or nightmares during which the event is reexpe-
rienced. In rare instances, there are dissociative-like states, lasting from a
few minutes to several hours or even days, during which components of the
event are relived and the individual behaves as though experiencing the
event at that moment. Such states have been reported in combat veterans.
Diminished responsiveness to the external world, referred to as “psychical
numbing” or “emotional anesthesia,” usually begins soon after the trau-
matic event. A person may complain of feeling detached or estranged from
other people, that he or she has lost the ability to become interested in pre-
viously enjoyed significant activities, or that the ability to feel emotions of
any type, especially those associated with intimacy, tenderness, and sexual-
ity, is markedly decreased.
After experiencing the stressor, many develop symptoms of excessive
autonomic arousal, such as hyperalertness, exaggerated startle response,
and difficulty falling asleep. Recurrent nightmares during which the trau-
matic event is relived and which are sometimes accompanied by middle or
terminal sleep disturbance may be present. Some complain of impaired
memory or difficulty in concentrating or completing tasks. In the case of
life-threatening trauma shared with others, survivors often describe painful
guilt feelings about surviving when many did not, or about the things they
had to do in order to survive. Activities or situations that may arouse rec-
ollections of the traumatic event are often avoided. Symptoms characteris-
tic of Post-traumatic Stress Disorder are often intensified when the
individual is exposed to situations or activities that resemble or symbolize
the original trauma (e.g., cold snowy weather or uniformed guards for
death-camp survivors, hot, humid weather for veterans of the South
Pacific). . . .
404 — The Psychoboom
Diagnostic Criteria for Post-traumatic Stress Disorder

A. Existence of a recognizable stressor that would evoke significant symp-

toms of distress in almost everyone.
B. Reexperiencing of the trauma as evidenced by at least one of the
following:
1. recurrent and intrusive recollections of the event
2. recurrent dreams of the event
3. sudden acting or feeling as if the traumatic event were recurring,
because of an association with an environmental or ideational stim-
ulus
C. Numbing of responsiveness to or reduced involvement with the exter-
nal world, beginning some time after the trauma, as shown by at least
one of the following:
1. markedly diminished interest in one or more significant activities
2. feeling of detachment or estrangement from others
3. constricted affect
D. At least two of the following symptoms that were not present before
the trauma:
1. hyperalertness or exaggerated startle response
2. sleep disturbance
3. guilt about surviving when others have not, or about behavior
required for survival
4. memory impairment or trouble concentrating
5. avoidance of activities that arouse recollection of the traumatic
event
6. intensification of symptoms by exposure to events that symbolize or
resemble the traumatic event

From: “Post-traumatic Stress Disorder,” American Psychiatric Association, Diag-

nostic and Statistical Manual of Mental Disorders, Third Edition (Washington, DC:
American Psychiatric Association, 1980). Reprinted with permission from the
Diagnostic and Statistical Manual of Mental Disorders, Third Edition. Copyright 1980.
American Psychiatric Association.
 Psychiatrists Debate Osheroff v. Chestnut Lodge — 405

Psychiatrists Debate
Osheroff v. Chestnut Lodge
(1990)

Rafael Osheroff was a forty-two-year-old physician with a history of

depression and anxiety when he was admitted to the psychiatric
treatment center Chestnut Lodge in January 1979. Hospitalized for
seven months, Osheroff later filed a lawsuit against the center, in
1982, claiming that by refusing to give him appropriate psychiatric
medication, Chestnut Lodge was responsible for his losing his liveli-
hood, his reputation, and the custody of his children. Before a trial
took place, both parties reached an out-of-court settlement, in
October 1987.
In 1990, two prominent psychiatrists debated the meaning of the
case in a now famous exchange in the American Journal of Psychiatry.
The psychiatrist Gerald Klerman (1928–1992) had been the former
head of the federal mental health agency and a witness in the trial
on behalf of Osheroff. In the 1970s and 1980s, he had been a lead-
ing figure among what he dubbed the “neo-Kraepelinians”—a
group of psychiatrists who generally believed that discrete, identifi-
able mental illnesses existed, that psychiatric research should be ori-
ented toward finding valid diagnostic criteria, and that therapy
should be aimed at treating disorders as illnesses. Alan Stone
entered the debate a trained psychoanalyst, a professor of law and
psychiatry at Harvard University, and a former president of the
American Psychiatric Association. As quickly becomes evident in
the excerpts below, the Osheroff case raised two important ques-
tions: Are drugs more effective than psychotherapy in treating men-
tal disorders? And how should we evaluate the effectiveness of
treatments?
406 — The Psychoboom
Gerald L. Klerman, M.D., “The Psychiatric Patient’s Right to
Effective Treatment: Implications of Osheroff v. Chestnut Lodge”

The patient, Dr. Rafael Osheroff, a 42-year-old white male physician, was
admitted to Chestnut Lodge in Maryland (in the Washington, D.C., met-
ropolitan area) on Jan. 2, 1979. His history included brief periods of depres-
sive and anxious symptoms as an adult; these had been treated on an
outpatient basis. He had completed medical school and residency training,
was certified as an internist, and became a subspecialist in nephrology. He
was married and had three children—one with his current wife and two
with his ex-wife.
Before his 1979 hospitalization, Dr. Osheroff had been suffering from
anxious and depressive symptoms for approximately 2 years and had been
treated as an outpatient with individual psychotherapy and tricyclic anti-
depressant medications. Dr. Nathan Kline, a prominent psychopharmacol-
ogist in New York, had initiated outpatient treatment with tricyclic
medication, which according to Dr. Kline’s notes, produced moderate
improvement. The patient, however, did not maintain the recommended
dose, his clinical condition worsened, and hospitalization was recommended.
The patient was hospitalized at Chestnut Lodge for approximately 7
months. During this time he was treated with individual psychotherapy
four times a week. He lost 40 pounds, experienced severe insomnia, and
had marked psychomotor agitation. His agitation, manifested by incessant
pacing, was so extreme that his feet became swollen and blistered, requir-
ing medical attention.
The patient’s family became distressed by the length of the hospital-
ization and by his lack of improvement. They consulted a psychiatrist in
the Washington, D.C., area, who spoke to the hospital leadership on the
patient’s behalf. In response, the staff at Chestnut Lodge held a clinical con-
ference to review the patient’s treatment. They decided not to make any
major changes—specifically, not to institute any medication regimen but to
continue the intensive individual psychotherapy. Dr. Osheroff’s clinical
condition continued to worsen. At the end of 7 months, his family had him
discharged from Chestnut Lodge and admitted to Silver Hill Foundation in
Connecticut.
On admission to Silver Hill Foundation, Dr. Osheroff was diagnosed as
having a psychotic depressive reaction. His treating physician began treat-
 Psychiatrists Debate Osheroff v. Chestnut Lodge — 407
ment with a combination of phenothiazines and tricyclic antidepressants.
Dr. Osheroff showed improvement within 3 weeks and was discharged
from Silver Hill Foundation within 3 months. His final diagnosis was
manic-depressive illness, depressed type.
Although the patient’s final diagnosis on discharge from Silver Hill was
manic-depressive illness, depressed type, testimony of the treating physi-
cian at Silver Hill revealed that, of the two DSM-II diagnoses that would
subsume a depressive illness as severe as Dr. Osheroff’s (manic-depressive
illness, depressed type, and psychotic depressive reaction), the diagnosis of
manic-depressive, depressed type, was selected because of the potential
future complications regarding child custody that could arise from a diag-
nostic label including the term “psychotic.” The Silver Hill physician fur-
ther testified that she did not find evidence of a narcissistic personality
disorder in Dr. Osheroff and that the correct diagnosis according to the
DSM-III terminology would be major depressive episode with psychotic
features.
Following his discharge from Silver Hill Foundation in the summer of
1979, the patient resumed his medical practice. He has been in outpatient
treatment, receiving psychotherapy and medication. He has not been
hospitalized and has not experienced any episodes of depressive symp-
toms severe enough to interfere with his professional or social function-
ing. He has resumed contact with his children and has also become
socially active. . . .
According to Chestnut Lodge records, there were differences in med-
ical opinion as to the relative importance to be given the patient’s person-
ality conflicts and his depressive diagnosis as they influenced treatment
decisions, not over the depressive diagnosis itself. As was the practice at the
institution, the patient had two physicians, a psychiatrist-administrator and
a psychotherapist. The hospital records suggest there may have been dis-
agreement between these two physicians: the psychotherapist emphasized
the need to treat the patient’s personality problems as the major condition,
and the administrator expressed concern over the continued severity of the
patient’s depressive symptoms and distressed behavior.
This aspect of the clinical process illustrates the tendency for many
psychoanalytically oriented psychotherapists, both in institutional and in
community practice, to focus treatment on a patient’s personality conflict
and character pathology rather than on symptoms. In DSM-III terms,
408 — The Psychoboom
there tends to be an emphasis on the axis II diagnosis and relatively little
attention given to the axis I diagnosis. The axis I diagnosis, a severe
depression in the case of Dr. Osheroff, is often missed, or, even if it is for-
mulated, the personality disorder is chosen as the major target for treat-
ment planning.

scientific evidence for evaluating psychiatric treatment

With regard to all kinds of therapeutics—pharmacotherapy, surgery, radi-
ation, psychotherapy—the most scientifically valid evidence as to the safety
and efficacy of a treatment comes from randomized controlled trials when
these are available. Although there are other methods of generating evi-
dence, such as naturalistic and follow-up studies, the most convincing evi-
dence comes from randomized controlled trials.
There have been many controlled clinical trials of psychiatric treat-
ments; most have been conducted to evaluate psychopharmacological
agents. These trials were initiated in the 1950s and 1960s in response to
the controversy that followed the introduction of chlorpromazine, reser-
pine, and other “tranquilizers.” The application of controlled trials in
psychopharmacology expanded after the passage in 1962 of the Kenfauver-
Harris Amendments to the Food, Drug, and Cosmetic Act, which man-
dated evidence of efficacy before a pharmaceutical compound could be
approved by the Food and Drug Administration and marketed.
Research on the efficacy of psychotherapy has lagged behind that of
psychopharmacology but has, nevertheless, been extensive. Smith et al.*
analyzed more than 400 reports of psychotherapy research. Specific reviews
of the evidence have appeared with regard to psychotherapy of neurosis,
schizophrenia, depression, and obsessive-compulsive disorders.
In view of these developments, a review of the state of evidence regard-
ing the treatments of the two psychiatric conditions for Dr. Osheroff at the
time of his hospitalization is in order.
With regard to the treatment of the patient’s diagnosis of narcissistic
personality disorder, there were no reports of controlled trials of any phar-
macological or psychotherapeutic treatment for this condition at the time
of his hospitalization. The doctors at Chestnut Lodge decided to treat Dr.

*Author’s note: M. L. Smith, G. V. Glass, and T. I. Miller, The Benefits of Psycho-

therapy (Baltimore: Johns Hopkins University Press, 1980).
 Psychiatrists Debate Osheroff v. Chestnut Lodge — 409
Osheroff’s personality disorder with intensive psychotherapy based on
psychodynamic theory.
With regard to the treatment of the patient’s DSM-II diagnosis of psy-
chotic depressive reaction, there was very good evidence at the time of his
hospitalization for the efficacy of two biological treatments—ECT and the
combination of phenothiazines and tricyclic anti-depressants. The combi-
nation pharmacotherapy was the treatment later prescribed at Silver Hill
Foundation.
There are no reports of controlled trials supporting the claims for effi-
cacy of psychoanalytically oriented intensive individual psychotherapy of
the type advocated and practiced at Chestnut Lodge and administered to
Dr. Osheroff. The closest approximation to a controlled clinical trial of this
form of intensive individual psychotherapy has been reported with hospi-
talized schizophrenic patients at two institutions in the Boston area. Con-
trary to the expectations of the investigators, one of whom was Dr. Alfred
Stanton (who had held a senior position at Chestnut Lodge and was one of
the authors of The Mental Hospital, which describes the Chestnut Lodge
institution), the results indicated that intensive individual psychotherapy
offered no advantage over standard treatment (hospitalization, medication,
and supportive psychotherapy) for these patients.
McGlashan and Dingman* have reported results from follow-up stud-
ies of groups of patients treated at Chestnut Lodge. The findings from this
naturalistic study do not support the efficacy of long-term psychotherapy
and hospitalization for severely depressed patients such as Dr. Osheroff.
It should not be concluded that there is no evidence for the value of
any psychotherapy in the treatment of depressive states. Depressive
states are heterogeneous, and there are many forms of psychotherapy.
There is very good evidence from controlled clinical trials for the value of
a number of brief psychotherapies for non-psychotic and nonbipolar
forms of depression in ambulatory patients. The psychotherapies for which
there is evidence include cognitive-behavioral therapy, interpersonal

*Author’s note: T. H. McGlashan, “The Chestnut Lodge Follow-Up Study, III:

Long-Term Outcome of Borderline Personalities,” Archives of General Psychiatry, 43
(1986): 20–30; C. W. Dingman and T. H. McGlashan, “Discriminating Charac-
teristics of Suicide: Chestnut Lodge Follow-Up Sample Including Patients with
Affective Disorders, Schizophrenia, and Schizoaffective Disorders,” Acta Psychiatrica
Scandinavica, 74 (1986): 91–97.
410 — The Psychoboom
psychotherapy, and behavioral therapy. However, no clinical trials have
been reported that support the claims for efficacy of psychoanalysis or
intensive individual psychotherapy based on psychoanalytical theory for
any form of depression.

biological versus psychodynamic psychiatry

Dr. Stone* raised the possibility that patients who have not improved after
prolonged psychotherapeutic treatment may have found a way around their
frustrations—a way provided by “biological psychiatrists.” Dr. Stone noted
that biological psychiatry appears to be on the scientific ascendancy over
psychodynamic psychiatry due to the prestige of the neurosciences and the
evidence for efficacy of biological treatments.
My conclusion, however, is that the issue is not psychotherapy versus
biological therapy but, rather, opinion versus evidence. The efficacy of
drugs and other biological treatments is supported by a large body of con-
trolled clinical trials. This body of evidence is all the more relevant to pub-
lic policy in view of the paucity of studies indicating efficacy for individual
psychotherapy.
It is regrettable that psychoanalysts and psychodynamic psychothera-
pists have not developed evidence in support of their claims for therapeutic
efficacy. Twenty years ago, psychodynamic psychotherapy was the domi-
nant paradigm of psychiatry in the United States, particularly in academic
centers. A number of European psychiatrists, mostly psychoanalysts, con-
tributed intellectual leadership and imaginative ideas to psychiatry here.
Currently, however, psychoanalysis is on the scientific and professional
defensive. This situation is, in part, a consequence of the failure of psycho-
analysis to provide evidence for the efficacy of psychoanalysis and psycho-
dynamic treatments for psychiatric disorders.
In the period between World War I and World War II, biological psy-
chiatry was in poor repute. Numerous treatments, often of a heroic nature,
were advocated: colonic resection, adrenalectomy, excision of teeth, lobot-
omy. These interventions were based on biological laboratory research of
dubious quality and without any systematic studies of safety and efficacy.
The situation has changed after World War II, with evidence for the value

*Author’s note: A. A. Stone, “The New Paradox of Psychiatric Malpractice,” New

England Journal of Medicine, 311 (1984): 1384–1387.
 Psychiatrists Debate Osheroff v. Chestnut Lodge — 411
of ECT for depression and insulin coma therapy for schizophrenia and,
later, with the introduction of chlorpromazine and other drugs.

the respectable minority doctrine

The Case of Osheroff v. Chestnut Lodge prompts the reevaluation of the doc-
trine of the respectable minority. Until recently, this doctrine held that if a
minority of respected and qualified practitioners maintained a standard of
care, this was an adequate defense against malpractice. I propose that this
doctrine no longer holds if there is a body of evidence supporting the effi-
cacy of a particular treatment and if there is agreement within the profes-
sion that this is the proper treatment of a given condition. Moreover, the
respectable minority have a duty to inform the patient of the alternative
treatments. In an unpublished 1985 paper discussing Osheroff v. Chestnut
Lodge, K. Livingston wrote,

Under this review, the respectable minority view would still consti-
tute a defense to a malpractice action where even 10% of practitioners
would adhere to the treatment in question. However, the shield of the
respectable minority rule would not be available unless the patient had
been given informed consent after a disclosure of risk/benefits and alter-
natives to the therapy.

how do we proceed in the absence of consensus?

When there is consensus in the profession as to the appropriate treatment
for a given condition (in the case of Osheroff, the essential nature of biolog-
ical treatment for severe depression), then a standard of care can be agreed
on and can provide the basis for malpractice action.
However, how are we to evaluate claims for the efficacy of treatments
for clinical conditions about which there is no consensus? What are the
standards to be applied in diagnostic and clinical situations where there is
no consensus within the field with regard to the treatment of the particular
disorder? This is a serious policy question that, in the future, may become
a legal question. In my opinion, there are three aspects to this issue: 1)
What constitutes evidence for efficacy? 2) Who is responsible for generat-
ing the evidence? and 3) Who is to make the appropriate evaluation of
treatments?
What constitutes evidence of treatment? In my view, the best available evi-
dence as to efficacy comes from controlled trials. I am not taking the
412 — The Psychoboom
position that the only source of evidence for efficacy comes from such tri-
als. Clinical experience, naturalistic studies, and follow-up studies are also
sources of relevant evidence. However, when results from controlled clini-
cal trials are available, they should be given priority in any discussion of sci-
entific evidence.
Who should be responsible for generating the evidence? What should be
society’s policy in regard to treatments for which there is no positive or
negative evidence? This issue has not reached resolution, and I feel it mer-
its further discussion within the profession.
My opinion is that the responsibility for generating evidence for efficacy
rests with the individual, group, or organization that makes the claim for
the safety and efficacy of a particular treatment. In the case of drugs, this
responsibility is established by statute. If a pharmaceutical firm makes a
claim for efficacy of one of its products, it must generate enough evidence
to satisfy the Food and Drug Administration before it can market the drug
for prescription use.
No such mandate of responsibility exists for psychotherapy. Anyone
can make a claim for the value of a form of psychotherapy—psychoanaly-
sis, Gestalt, est, primal scream, etc.—with no evidence as to its efficacy.
What should be our position toward the claims of the efficacy in cer-
tain conditions of multiple treatments for which the evidence varies in qual-
ity and quantity? In my view, those treatments which make claims but have
not generated evidence are in a weak position.
The efficacy of psychoanalysis and psychoanalytic treatments is in
question for conditions for which there is evidence of efficacy with other
treatments. For example, how many psychiatrists would justify long-term
psychoanalytic treatment of panic disorder and/or agoraphobia when there
is no evidence that this treatment works for these disorders but reasonably
good evidence for the efficacy of certain drugs and/or forms of behavioral
psychotherapy?
Who is to evaluate the evidence? A major problem arises as to the process
by which the evidence regarding psychiatric treatments is to be evaluated.
I believe there are serious deficiencies in our current professional and gov-
ernmental arrangements for evaluating psychiatric treatments. In the case
of drugs, we have the Food and Drug Administration, which makes such
judgments according to established legal statutes and regulatory processes.
There is no comparable statutory mandate for assessing the efficacy and
 Psychiatrists Debate Osheroff v. Chestnut Lodge — 413
safety of non-pharmacological treatments such as radiation, surgery, and
psychotherapy.
In this situation, I believe the public has the right to expect that the
medical profession will provide appropriate judgments as to the state of the
evidence for treatments and establish criteria for standards of care. I main-
tain that the psychiatric profession has been lax in this responsibility and
that the absence of professional consensus statements in our field leaves it
open for the courts to be used by individuals, such as Dr. Osheroff, who
feel they have been poorly treated and who believe they are entitled to
redress of their grievances.
The fact that evidence changes is to my mind irrelevant to any policy
or clinical discussion. The judgment on treatment of individual patients
should be made according to the state of knowledge and professional prac-
tice at the time the individual patient is treated. In the case of Osheroff, this
was 1979.
My strong preference would be for the profession to be more vigorous
and more responsible in accepting this responsibility. I have stated these
views on numerous occasions.

Alan A. Stone, “Law, Science, and Psychiatric Malpractice:

A Response to Klerman’s Indictment of Psychoanalytic Psychiatry”

Malcolm’s book* reports that Dr. Osheroff was married three times before
his hospitalization. His first marital relationship began while he was in col-
lege and ended in divorce after 21 months because his wife had been
unfaithful. He thought of leaving medical school but saw a psychiatrist who
convinced him to return. During his internship he met and married a
nurse. The second marriage lasted much longer but deteriorated after the
birth of two children. Dr. Osheroff saw a psychiatrist again during these
years while he was establishing his practice. According to Malcolm, he
wrote about this period of time in his autobiography, which he entitled A
Symbolic Death:

All during the early years of my [second] marriage, I had been rather
immature and insensitive and my energies seemed to be devoted to and

*Editor’s note: The author refers here to John Malcolm, Treatment Choices and
Informed Consent (Springfield, IL: Charles C. Thomas, 1988).
414 — The Psychoboom
focused on my career, that I perhaps was not listening and if I was lis-
tening, perhaps I wasn’t hearing. I was seemingly oblivious to the
stresses that were developing in my marriage at the time.

Psychotherapy for Dr. Osheroff and marital therapy for the couple did
not save the marriage. His second wife left the children with him and went
off with another man. Dr. Osheroff lost 40 pounds during this time, living
“a life that was almost devoid of the usual types of satisfaction.” His
nephrology practice, nonetheless, grew and prospered as he opened his
own dialysis center. He then met his third wife, a medical student on her
clinical clerkship, and married her after a “whirlwind romance.” This was
at first a happy and successful marriage, and symptoms of depression appar-
ently disappeared. He and his wife were, in his words, “one of the most cel-
ebrated and sought after medical couples in the . . . area.”
There were continuing conflicts, however, with his second wife, who
now wanted custody of their two children. Conflicts also began with his
third wife. They were precipitated, according to her, by his seemingly
inconsiderate behavior during the birth of their first child (his third) and
his lack of attention to the baby and her.
Dr. Osheroff also began to have serious disagreements with his profes-
sional associates in practice. With these conflicts and the deterioration of
his third marriage, he saw at least three different psychiatrists, two of whom
prescribed antidepressive medication, which was not successful—perhaps
because of lack of compliance. It is well recognized that “drug manipulation
and drug compliance are anticipated problems” in patients whose affective
symptoms are complicated by personality disorders.* No doubt, such prob-
lems can be even greater when the patient is himself a physician and may
have his own opinions about treatment.
I do not mean to suggest that Klerman intentionally selected from the
history only those features which support his diagnosis and the basic the-
sis of his paper. Perhaps the kinds of subjective experiences revealed in Dr.
Osheroff’s autobiographical account and the interpersonal difficulties he
experienced with the important people in his life, which suggest problems

*Author’s note: J. O. Cole and P. S. Sunderland III, “The Drug Treatment of Bor-
derline Patients,” in Psychiatry 1982: The American Psychiatric Association Annual
Review ed. L. Grinspoon (Washington, DC: American Psychiatric Association,
1982).
 Psychiatrists Debate Osheroff v. Chestnut Lodge — 415
in the sphere of object relations and character, have become less relevant to
psychiatrists who tend to overemphasize DSM-III’s axis I in comparison
with axis II. Perhaps these two quite different histories indicate that there
is an incorrigible diagnostic and conceptual difference between Klerman’s
school and traditional psychiatrists. The “scientific” psychiatrist now looks
for the symptoms. The traditional psychiatrist still looks for the person.
Each school can criticize the blindness of the other on the basis of its own
criteria.
In any event, when Dr. Osheroff entered Chestnut Lodge he was not
a neophyte as to psychiatry or its various therapeutic approaches, nor was
he professionally or personally ignorant about depression. He was a physi-
cian who, I have no doubt, had already several times in his life been diag-
nosed, fully informed about his diagnosis, and treated exactly in the
manner recommended by Klerman in his paper. Those treatment methods
had failed. All of this seems relevant to any judgment about Chestnut
Lodge’s alleged negligence and the lessons Klerman claims are to be
learned from this litigation.

the treatment
The breakdown of Dr. Osheroff’s third marriage and his professional con-
flicts, which precipitated his hospitalization, could reasonably have been
understood at the time as classic examples of the kind of psychosocial crises
that destroy the precarious balance of the narcissistic personality. Even if
Klerman believes that this kind of psychodynamic formulation and
approach to treatment is no longer “scientifically” acceptable, there can be
little doubt that it was well within the collective sense of the profession in
1979. Thus, I suggest that the initial treatment program for Dr. Osheroff
was acceptable, particularly in light of a history of previous unsuccessful
drug treatment provided by a leading psychopharmacologist and imple-
mented by his traditional psychotherapist.
With only this psychodynamically oriented psychotherapy, however,
the patient’s condition obviously deteriorated. Whatever the original
diagnosis and treatment plan were, reevaluation and consultation are
required at some point when a treatment regimen has such obviously
negative consequences. I have no doubt that during the 1950s, 1960s,
and 1970s at Chestnut Lodge and other similarly oriented hospitals, tra-
ditional therapists did persist in exclusive psychoanalytic psychotherapy,
416 — The Psychoboom
despite similar situations of obvious symptomatic deterioration. My own
clinical experience at McLean Hospital during these years certainly con-
firms this impression.
If Klerman had stayed with this narrow fact of the situation and stated
that exclusively psychoanalytic treatment of a hospitalized patient in the
face of obvious psychotic deterioration is no longer clinically acceptable, I
believe he could have claimed to speak for the collective sense of the pro-
fession, including the vast majority of traditional psychotherapists.
It is important to recognize that this marks an important historical
moment of transition in modern psychiatry. Many new considerations as
well as efficacy studies have led to this change. The biological dimensions
of serious mental disorders and their treatment have been better under-
stood, and this understanding has been more widely accepted. The conse-
quences of longer periods of psychotic decompensation have been more
fully recognized. The distinction between social recovery with improve-
ment of symptoms and the cure of serious mental illness has been better
appreciated, and psychiatric hospitalization has increasingly focused on the
former. The negative implications of long-term hospitalization of patients
with psychotic disorders have been well documented. Psychiatrists have
recognized the importance of improvement in symptoms for the therapeu-
tic alliance and, therefore, as a necessary part of treatment with seriously
disturbed patients. The limitations of traditional therapy with psychotic
patients are widely accepted, and successful treatment is more often attrib-
uted to the unique qualities of the therapist or the relationship rather than
to the method of the psychotherapy. All of these factors and not just the
available efficacy studies have led to the changes in the collective sense of
the profession.
At Chestnut Lodge, Dr. Osheroff apparently developed a negative ther-
apeutic reaction and a negative transference to both the therapist and the
hospital. The person suffering from these serious symptoms of depression
was in revolt against his treatment. The recommendation to change hospi-
tals seems to me eminently sound on psychodynamic grounds. Klerman
suggests that Dr. Osheroff’s remarkable cure at the Silver Hill Foundation
was a function of his finally being provided the efficacious combination of
tricyclics and phenothiazines. If all patients like Dr. Osheroff had such
remarkable cures with these drugs, psychiatry would be a different profes-
sion. But Dr. Osheroff’s psychological response to Silver Hill Foundation,
 Psychiatrists Debate Osheroff v. Chestnut Lodge — 417
as described in his autobiography, suggests that other, equally important,
psychodynamic factors were involved. He had escaped, if not narcissistically
triumphed over, Chestnut Lodge and his therapist. His negative transfer-
ence had been vindicated. Such psychodynamic conceptions still seem as
relevant to our clinical understanding of such remarkable cures as does
psychopharmacology.

biological versus psychodynamic psychiatry

Klerman and Klein have both objected to my characterization of the
Osheroff dispute as one between biological and psychodynamic psychiatry.
Klerman here states that it is, rather, a matter of opinion versus evidence.
Klein* has made the same point in stronger and more colorful language.
Both of them contend that they are speaking as scientists and that the issue
is one of scientific evidence versus dogmatic opinion. Klerman makes this
a thesis of his current paper, applying it as a standard to all psychiatric treat-
ments. I believe both men ignore the very real problem of differing opinions
about scientific evidence and the canons of science within the psychiatric
profession. Klerman and Klein surely recognize that the quality of evi-
dence, even in their own impressive research, leaves room for other scien-
tists to make interpretations and raise questions. The basic assumption on
which clinical research on depression and panic states proceeds are subject
to fundamental questions by serious scientists. Klerman is no doubt correct
that at a meeting of scientists, the person with evidence should take prece-
dence over the person without evidence. Even a small amount of evidence
is better than opinion when the question is what can science say about a
subject. But that does not mean the science is good enough to create a uni-
form policy or to dictate to clinicians the clinical standards of care. . . .

efficacy research and public policy concerns

There is an apocryphal story told about male lawyers. One asks the other,
“How is your spouse?” The other replies, “Compared to what?” “Com-
pared to what” is the appropriate perspective to bring to Klerman’s discus-
sion of efficacy research and policy. He compares psychotherapy and drugs.
In that comparison he criticizes the failure of various government agencies

*Author’s note: D. F. Klein, “The Osheroff Case: A Rebuttal,” Psychiatric News 7

April 1989: 26.
418 — The Psychoboom
at the federal and state levels. He also criticizes his colleagues in research
and in professional associations. When compared to Food and Drug
Administration safety and efficacy standards for drugs, the regulation of
psychotherapy seems to stand out as a public policy disaster. But virtually
everything Klerman says about psychotherapy applies with equal force to
surgery and almost everything that physicians do which does not come
under the Food and Drug Administration’s authority. Much of what all
physicians do has no demonstrated effectiveness—even the prescription of
supposedly efficacious medication. Thus, if psychotherapy is compared to
surgery, for example, one might get a totally different impression about the
nature and significance of the public policy problem posed by traditional
psychotherapy. It turns out that the Food and Drug Administration is quite
unique, holding the massive pharmaceutical industry hostage and able to
require it to invest vast resources in research into efficacy and safety. Thus,
Klerman’s use of the Food and Drug Administration as a model is less rel-
evant and less meaningful than it seems.
All health policy experts are concerned about efficacy. Indeed, efficacy
research has become the central requirement of what Relman* called the
third revolution in medical care, requiring increased attention to assess-
ment and accountability. In order to meet the pressing objectives of quality
and cost control, however, Relman wrote, “We will also need to know
much more about the relative costs, safety, and effectiveness of all the
things physicians do or employ in the diagnosis, treatment and prevention
of disease.” Relman was commenting on an article by Roper et al. of the
Health Care Financing Administration, who described new “effectiveness
initiatives.” These will increasingly involve the federal government in the
collection and distribution of efficacy and outcome data concerning many
branches of medicine. Roper et al.,† along with Relman, stated that more
comprehensive assessment of medical effectiveness will eventually improve
the quality of care and eventually help curtail costs. Unlike Klerman, they
suggested that the science of efficacy research currently available in the rest

*Author’s note: A. S. Relman, “Assessment and Accountability: The Third Revo-

lution in Medical Care (Editorial),” New England Journal of Medicine 319 (1988):
1220–1222.
†
Author’s note: W. L. Roper, W. Winkenwerder, G. M. Hackbarth, et al., “Effec-
tiveness in Health Care: An Initiative to Evaluate and Improve Medical Practice,”
New England Journal of Medicine 319 (1988): 1197–1202.
 Psychiatrists Debate Osheroff v. Chestnut Lodge — 419
of medicine is inadequate to the task. The focus of the Health Care Financ-
ing Administration was on surgery. For example, they cited carotid
endarterectomy and the implantation of cardiac pacemakers as examples of
surgical practices often used inappropriately because of the lack of adequate
efficacy studies. More money is certainly spent on these procedures than on
all of the traditional psychotherapy provided in the United States—and the
immediate risks of their use or misuse are much greater. Roper et al. clearly
recognized what Klerman has not: that the “science of health care evalua-
tion, still in its formative stages, requires certain resources: money, data,
and people trained in the evaluative sciences” and that “methods of gather-
ing and synthesizing data on health outcomes and effectiveness are corre-
spondingly underdeveloped.”
Roper et al. made it clear that a whole new infrastructure for gathering
data is necessary before sensible public policy can be developed to control
clinical practice. They did not blame the medical profession for this gap in
our scientific knowledge. Klerman’s paper, in contrast, seems to be a rush
to judgment, with the first stop at the courthouse. Klerman does not even
acknowledge that there is any legitimate opposition to his views. He is pre-
pared to argue that “the absence of professional consensus statements in
our field leaves it open for the courts to be used by individuals, such as Dr.
Osheroff, who feel they have been poorly treated and who believe they are
entitled to redress of their grievances.” This is to suggest that the psychi-
atric profession is now being punished for its own sins of laxity, which
opened the door to the courtroom. This is simply nonsense. Every legal
scholar writing on the subject of psychiatric malpractice has pointed to the
lack of professional consensus in psychiatry as a major cause for the
remarkable dearth of such litigation compared to other specialties over the
past century. In fact, any experienced lawyer would say that Dr. Osheroff
was able to litigate because he was able to obtain expert witnesses like Kler-
man and his distinguished colleagues, who were willing to testify that there
is a consensus about efficacious treatment. Indeed, Klerman’s paper is an
attempt to assert and establish this thesis.
The use of the courtroom and malpractice litigation to enforce a con-
sensus policy on efficacy would have serious consequences for biological
psychiatry as well as for the field as a whole. The history of neuroleptic
medication for psychiatric disorders presents a striking example. Psychia-
try’s understanding of efficacious doses and deleterious side effects has
420 — The Psychoboom
changed dramatically over the past two decades. We have gone from
smaller doses to megadoses back to smaller doses. We have gone from rou-
tine maintenance to selective intramuscular “neurolepticization” for acute
psychotic disorders and abandoned it. All of these changing standards of
care were based on clinical experience, available scientific evidence, and a
genuine concern for providing effective treatment. If, at any early point in
this history, biological psychiatrists had gone to court or to any other offi-
cial authority to impose efficacious dose standards on all their colleagues, it
would have been a disaster for our patients and for biological psychiatry. If
it is Klerman’s idea that psychiatry should be ruled by the courts applying
the prevailing scientific evidence of the day, he has a recipe for disaster.*

From G. L. Klerman, “The Psychiatric Patient’s Right to Effective Treatment: Impli-

cations of Osheroff v. Chestnut Lodge,” American Journal of Psychiatry 147 (1990):
409–418 and A. A. Stone, “Law, Science, and Psychiatric Malpractice: A Response
to Klerman’s Indictment of Psychoanalytic Psychiatry,” American Journal of Psychia-
try 147 (1990): 419–427. Reprinted with permission from the American Journal of
Psychiatry, American Psychiatric Association. Copyright 1990.

*Editor’s note: Only those notes have been included in which the authors name a
specific citation in the main text.
 Appendix

Bibliography of First-Person
Narratives of Madness in English
(Fourth Edition)

Gail A. Hornstein

This bibliography is in four sections: (1) personal accounts of mad-

ness written by survivors themselves; (2) narratives written by fam-
ily members; (3) anthologies and critical analyses of the madness
narrative genre; and (4) Web sites featuring oral histories and other
first-person madness accounts.

Last revised in November 2008 with assistance from Cheryl

McGraw, Catherine Riffin, and Moriah Silver.

Please send corrections, additions, comments or inquiries to

Gail A. Hornstein
Professor of Psychology
Mount Holyoke College
South Hadley, MA 01075
USA
[email protected]

421
422 — Appendix
Personal Accounts of Madness by Survivors Themselves

Abrams, Albert. 1895. Transactions of the Antiseptic Club. New York: E. B. Treat.
Adams, Brian. 2003. The Pits and the Pendulum: A Life with Bipolar Disorder. Lon-
don: Jessica Kingsley.
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438 — Appendix
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440 — Appendix
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442 — Appendix
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 Bibliography of First-Person Narratives — 443
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444 — Appendix
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Zwiren, Scott. 1996. God Head. Dalkey Archive Press.

Narratives by Family Members

Anstadt, Sera. 2007. All My Friends Are Crazy. Translated from 1983 Dutch edi-
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Arthur, Jonathan. 2002. The Angel and the Dragon: A Father’s Search for Answers to
His Son’s Mental Illness and Suicide. Deerfield Beach, FL: Health Communica-
tions.
Bass, Elaine. 2006. A Secret Madness: The Story of a Marriage. London: Profile
Books.
Berger, Diane, and Lisa Berger. 1991. We Heard the Angels of Madness: One Fam-
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Bottoms, Greg. 2001. Angelhead: My Brother’s Descent into Madness. London:
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Brown, Josephine. 2007. Betrayal of Minds. London: Chipmunka.
Carrigan, John. 2008. The Other Side of Harry. London: Chipmunka.
446 — Appendix
Copeland, James. 1976. For the Love of Ann: The True Story of an Autistic Child. Lon-
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Craig, Eleanor. 1994. The Moon Is Broken: A Mother’s True Story. New York: Signet.
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Day, G.W.L. 1939. Rivers of Damascus. London: Rider.
Early, Pete. 2006. Crazy: A Father’s Search through America’s Mental Health Madness.
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Evans, Stan A. 2003. Box of Mustaches: The Darkly Funny True Story of How Twin
Brothers Survived Their Mother’s Madness. Lincoln, NE: iUniverse.
Ford, Joy. 2007. One in Four. London: Chipmunka.
Greenberg, Michael. 2008. Hurry Down Sunshine. New York: Other Press.
Gregory, Julie. 2003. Sickened: The Memoir of a Munchausen by Proxy Childhood.
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Hackett, Marie. 1954. The Cliff ’s Edge. New York: McGraw-Hill, 1954.
Helfgott, Gillian, with Alissa Tanskaya. 1997. Love You to Bits and Pieces: Life with
David Helfgott. New York: Penguin.
Hillman Paterson, Judith. 1997. Sweet Mysteries: A Southern Memoir of Family Alco-
holism, Mental Illness, and Recovery. New York: Farrar, Straus & Giroux.
Hinshaw, Stephen P. 2002. The Years of Silence Are Past: My Father’s Life with Bi-
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Johnston, Jean. 2005. To Walk on Eggshells (Is to Care for a Mental Illness). Helens-
burgh, UK: Cairn.
Kaufman, Barry Neil. 1976. Son Rise. New York: Harper & Row.
Kingsley, Jo, and Alice Kingsley. 2005. Alice in the Looking Glass: A Mother and
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Lachenmeyer, Nathaniel. 2000. The Outsider: A Journey into My Father’s Struggle
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Loudon, Mary. 2006. Relative Stranger: A Sister’s Life after Death. London:
Canongate.
Lyden, Jacki. 1997. Daughter of the Queen of Sheba: A Memoir. New York:
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Moorman, Margaret. 1992. My Sister’s Keeper: Learning to Cope with a Sibling’s Men-
tal Illness. New York: Norton.
Naylor, Phyllis. 1977. Crazy Love. New York: William Morrow.
Neale, R. M. 1998. To Challenge or Not to Challenge: A Family’s Response to a Son’s
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Neugeboren, Jay. 1997. Imagining Robert: Brothers, Madness, and Survival; A Mem-
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Pines, Paul. 2007. My Brother’s Madness. Willimantic, CT: Curbstone Press.
Raeburn, Paul. 2005. Acquainted with the Night: A Parent’s Quest to Under-
stand Depression and Bipolar Disorder in His Children. New York: Broadway
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Shields, Mary Lou. 1981. Sea Run: Surviving My Mother’s Madness. New York:
Seaview.
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Spungen, Deborah. 1984. And I Don’t Want to Live This Life. London: Corgi
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 Bibliography of First-Person Narratives — 447
Steel, Danielle. 2000. His Bright Light: The Story of Nick Traina. New York: Dell.
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UK: Sixties Press.
Townsend, Martin. 2008. The Father I Had. London: Transworld.
Tracey, Patrick. 2008. Stalking Irish Madness: Searching for the Roots of My Family’s
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Wilson, Louise. 1968. This Stranger, My Son. New York: Putnam.
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Wyden, P. 1998. Conquering Schizophrenia: A Father, His Son, and a Medical Break-
through. New York: Knopf.

Anthologies, Narrative Analyses, and Criticism

Alvarez, Walter C. 1961. Minds That Came Back. Philadelphia: J. B. Lippincott.

Aswell, Mary Louise. 1947. The World Within, Fiction Illuminating Neuroses of Our
Time; with an Introduction and Analyses by Frederic Wertham. New York: Whittle-
sey House.
Barker, Phil, Peter Campbell, and Ben Davidson, eds. 1999. From the Ashes of Expe-
rience: Reflections on Madness, Survival, and Growth. London: Whurr.
Beard, Jean J., and Peggy Gillespie, eds. 2002. Nothing to Hide: Mental Illness in the
Family. New York: New Press.
Berlin, Richard M., ed. 2008. Poets on Prozac: Mental Illness, Treatment, and the Cre-
ative Process. Baltimore: Johns Hopkins University Press.
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Web Sites Featuring First-Person Madness Narratives

Alaska Mental Health Consumers Website: http://www.akmhcweb.org

Antipsychiatry Coalition: http://www.antipsychiatry.org
Asylum Magazine: http://www.asylumonline.net
ECT: http://www.ect.org
Freedom Center: http://www.freedom-center.org
Hearing Voices Network: http://www.hearing-voices.org
Icarus Project: http://www.theicarusproject.net
Institute for the Study of Human Resilience: http://www.bu.edu/resilience
International Community for Hearing Voices: http://www.intervoiceonline.org
International Guide to the World of Alternative Mental Health:
http://www.alternativementalhealth.com
Law Project for Psychiatric Rights: http://psychrights.org
M-Power: http://www.m-power.org
Mad Not Bad: http://www.madnotbad.co.uk
Mad Pride: http://www.ctono.freeserve.co.uk
Mental Health Client Action Network of Santa Cruz County:
http://www.mhcan.org
Mental Health in the UK: http://www.zoo.pwp.blueyonder.co.uk
Mental Health Media: http://www.mhmedia.com
Mind: http://www.mind.org.uk
Mind Freedom International: http://www.mindfreedom.org
National Association for Rights Protection and Advocacy: http://www.narpa.org
National Empowerment Center: http://www.power2u.org
Pennsylvania Mental Health Consumers Association: http://www.pmhca.org
People Who: http://www.peoplewho.org
Prinzhorn Collection: http://prinzhorn.uni-hd.de/index_eng.shtml
Psychiatric Survivor Archives: http://psychiatricsurvivorarchives.com
Successful Schizophrenia: http://www.successfulschizophrenia.org
Survivors Art Foundation: http://www.survivorsartfoundation.org
page 452 is blank.
 Index

active therapy, 271–275 Carter, Dianne K., 392–401

agoraphobia, 223–228 Charcot, Jean-Martin, 193–200, 207,
Alcoholics Anonymous, 373–375 216–217
alcoholism, 255, 292, 300, 373–375 Christianity, 8, 36–39, 53–59, 68, 109,
alienists, 92–93, 104 122–123
antipsychiatry, 163–167, 232, 346–357 classification, 95–96, 111, 371–372,
anxiety, 390–391 401–404
Arabic medicine, 47–52 client-centered therapy, 376–382
Aristotle, 7 clinics, 93
asylums, 92, 96, 99, 134–167, 362–363 cognitive-behavioral therapy, 382–391, 409
atrabilis, 81–82 colonialism, 155–162, 333–345
.
Austria, 184–193, 207–223, 260–271
Avicenna (Ibn Si–na–), 50–52
communism, 312–332
community mental health, 232, 357–367
criminal responsibility, 78–79, 123–133
Basaglia, Franco, 352–357 Cullen, William, 85–89
Beard, George Miller, 175–179 cupping, 44
Beck, Aaron T., 382–391
Bedlam Hospital (London), 76, 135 Declaration of Hawaii, 329–332
Beers, Clifford, 276 degeneration, 229, 252–256, 296
Bernheim, Hippolyte, 218 deinstitutionalization, 232, 357–367
Bible, 10–17, 36–39 delusions, 35–36, 42, 51–52, 70, 101–102,
Bicêtre Hospital (Paris), 94–95, 97, 111–112, 124–133, 136–137, 183,
99–100 223–228, 248
bile, 81–82 depression, 203, 289–291, 393, 396
bloodletting, 44, 47–49 Diagnostic and Statistical Manual, 371–372,
Boerhaave, Hermann, 80–85 401–404, 407–408, 415
borderline syndrome, 393 Dionysus, 18–30
brain, 83, 86–87, 93, 96–97, 177, distraction, 76
283–293. See also neurology Dix, Dorothea, 116–123
Breuer, Joseph, 207–223 dreams, 141–142, 186, 189–190, 193,
Brydall, John, 73–80 249, 403–404
Buck v. Bell, 256–259 drugs, 83. See also medication
Burton, Robert, 67–72 drunkenness, 78–80

453
454 — Index
ecstasy, 18–30 Hogarth, William, 135
electricity, 87, 113, 160, 175–178, 235–238 homosexuality, 184–193, 299
emotions, 111–115, 123–124, 214–215, humors, 7, 9, 31, 48, 70, 72, 82, 84
284–289. See also passions hydrotherapy, 231, 245, 250–251, 277
England, 53–59, 67–84, 123–133, hypnosis, 184, 188–189, 192, 193–194,
233–244. See also Great Britain 210–211, 215–216, 218, 221, 235
Enlightenment, 91, 94 hysteria, 9, 30–36, 81, 187–188, 193–200,
epilepsy, 41, 43, 196–197, 199–200, 297, 207–223, 233–238
300, 306
Erasmus, Desiderius, 60–66 idiocy, 8–9, 73–76, 296–297
Esquirol, Jean Etienne, 111–115 India, 155–162
ethics, 329–332 insulin coma therapy, 275–282, 411
eugenics, 229, 231, 252–259, 294–311 Ireland, 143–154
Euripides, 18–30 Italy, 179–183, 352–357
euthanasia, 230–231, 304–311 Islam, 47–52

Fanon, Frantz, 333–345 Janet, Pierre, 217–218

feeble-mindedness, 256–259, 297, Jesus, 36–39
299–300, 305 Judaism, 8, 10–17
feminism, 392–401 Julian of Norwich, 53–59
folly, 8, 60–66, 73–80
France, 94–104, 111–115, 193–200, Kaufmann, Fritz, 233–238
333–345 Klerman, Gerald, 405–420
Freeman, Walter, 283–293 Kraepelin, Emil, 200–206
frenzy, 9, 21–22, 41 Krafft-Ebing, Richard, 184–193
Freud, Sigmund, 207–223
functional illness, 93, 175, 178, 233, laboratory, 93, 260
242–243, 336 law, 8, 73–80, 299–304, 405–420
Law for the Prevention of Hereditarily Ill
Gall, Franz Joseph, 168 Offspring, 299–304
general paresis, 230, 260–271 Lentz, Fritz, 294–299
Germany, 105–110, 200–206, 233–238, lobotomy, 231, 283–293
271–275, 294–317 lovesickness, 50–52
Great Britain, 357–367. See also England lunacy, 77–78
Greece, 18–39 Lundborg, Herman, 252–256
Grigorenko, Pyotr, 317–328
group therapy, 400 mad-doctors, 91–92, 105, 107–110
magnetism, 87, 110, 160
hallucinations, 48, 70, 179–183, 249–250, malaria fever therapy, 260–271
284–285, 312–317 malingering, 209, 233, 337
Heinroth, Johann Christian August, mania, 9, 39–46, 83–84, 89, 100–101
105–110 manic-depression, 245–251, 293, 300,
heredity, 253–254, 258–259, 294–304 406–407
Hippocrates, 30–36 marriage, 75–76
Hitler, Adolf, 231, 294, 299, 307 masturbation, 184–193
 Index — 455
medication, 201–202, 204–206, 351, 357, psychopathy, 111, 297–299, 327
363, 365–366 psychosis, 312–317, 363
melancholy, 9, 47–49, 67–72, 81–83, 225 psychosomatic, 105
men, 41, 187–193, 202, 204–206, 224, psychotherapy, 369, 376–401, 405–420
238–244, 298, 341–342
mental doctors. See mad-doctors race, 231, 253–256, 294–311, 333–345
mental illness, 346–351 randomized clinical trials, 371, 405–420
M’Naughten Rules, 123–133 Rawlings, Edna I., 392–401
Moniz, Egas, 283–284 reason, 41–42, 74–77, 80, 94, 98,
monomania, 111–115, 124 105–109, 111–112, 122, 163–164
moral treatment, 92, 94–104 repression, 219–223
music, 15–16 Rivers, W.H.R., 238–244
Rogers, Carl, 376–382
Nazism, 231, 294–295, 299–311 Roman Empire, 40–46
nerves and nervous system, 85–89, 93, 98, Romanticism, 105
179–183, 250 Rufus of Ephesus, 47–49
nervousness, 93, 164, 224–228, 233–234,
246, 297–298. See also neurasthenia Salpêtrière, 94, 111, 193–200
neurasthenia, 175–179, 187, 189 Saul, 10–17
neurology, 93, 168, 179–183, 283 Scandinavia, 252
neurosis, 85, 214, 229–230, 233–244 schizophrenia, 296–297, 300, 305, 312–317
Scotland, 85–89
onanism. See masturbation self-help, 360, 370, 373–375
Opal, The, 134–142 senility, 306–307
opium, 164 sexuality, 30–36, 52, 184–193, 296–297,
Osheroff, Rafael, 405–420 299, 341–342, 398
shellshock, 238, 402. See also neurosis
Packard, Elizabeth, 162–167 Simon, Hermann, 271–275
passions, 76, 82–83, 104. See also emotions simulation. See malingering
pessaries, 32–34 Sizer, Nelson, 168–174
pharmacology, 85, 370–371, 405–420. social psychiatry, 232, 352–367, 392
See also medication Soranus of Ephesus, 39–46
phobia. See agoraphobia soul, 57–59, 86–87, 105–110, 248, 277
phrenology, 93, 168–174 Soviet Union, 231–232, 317–329
physicians, 127, 129, 132–133, 135–137, sterilization, 228–229, 256–259, 299–304
208–209, 230, 299–304, 329–332 Stone, Alan, 405–420
Pinel, Philippe, 94–104 suicide, 35–36, 188, 203, 245, 287,
Plato, 7, 40, 68 289–290, 293, 295, 298, 354–355,
pneuma, 7 380–382
post-traumatic stress disorder, 401–404 Sweden, 252–256
prisons, 116–123 Szasz, Thomas, 346–351
progressive paralysis. See general paresis
psyche, 7, 108 Tamburini, Auguste, 179–183
psychoanalysis, 207–223, 238–244, 344, temperament, 87
371, 376, 383–384, 405–420 trauma, 211–217, 401–404
456 — Index
United States of America, 116–123, will, 104, 106–107, 110, 111–115,
134–142, 162–179, 256–259, 275–293, 123–124
346–351, 376–420 Willis, Francis, 91–92
unconscious, 221–223 women, 9, 21–22, 31–36, 41, 163–167,
urning. See homosexuality 202, 204–206, 298, 392–401
USSR. See Soviet Union work, 271–275
World Psychiatric Association, 329–332
Wagner-Jauregg, Julius, 260–271 World War I, 229–230, 233–244
Watts, James W., 283–293 World War II, 231
 About the Editor

Greg Eghigian is Director of the Science, Technology, and Society Program

and Associate Professor of Modern History at Penn State University. A his-
torian of psychiatry and the human sciences as well as of modern Germany,
he has written on the history of such topics as disability, criminal deviance,
pain and suffering, and the politics of science. His is the author and coedi-
tor of numerous books, including Making Security Social: Disability, Insur-
ance, and the Birth of the Social Entitlement State in Germany; Pain and
Prosperity: Reconsidering Twentieth-Century German History; and The Self as
Project: Politics and the Human Sciences in the Twentieth Century.