Mad Travelers: Reflections on the Reality of Transient Mental Illnesses (Page-Barbour Lectures) 0813918235, 9780813918235

Citation preview

M

1" J

REFLECTIONS T RA N SIE N T

ON

THE

ME N T A L

REALITY

OF

IL LNE SSE S

Page- Barbou r Lectu res for

1997

REFLECTIONS ON THE REALITY O F TRANSIENT

MENT A L

ILLNESSES

Ian Hacking

UNIVERSITY

PRESS

CHARLOTTESVILLE

OF

VIRGINIA

AND

LONDON

THE UNIVERSITY PRESS OF VIRGINIA

© 1998 by the Rector and Visitors of the University of Virginia All rights reserved Printed in the United States of America

First published 1998 © The paper used in this publication meets the mini­ mum requirements of the American National Standard for Information Sciences-Permanence of Paper for Printed Library Materials, ANSI Z39.48-1984.

Library of Congress Cataloging-in-Publication Data Hacking, Ian. Mad travelers: reflections on the reality of transient mental illnesses I Ian Hacking. p.

cm.

"Page-Barbour lectures for 1997"-CIP t.p. verso. Includes bibliographical references and index. ISBN 0-8139-1823-5 (cloth: alk. paper) i.

Fugue (Psychology)-Case studies. 2. Tissie, Philippe.

1852-1925. 3. Social psychiatry. 4. Niche (Ecology) I. Title. RC553.F83H33

1998

98-20894

6i6.85'232-dc21

Frontispiece:

Dr. Phillipe Tissie hypnotizing Albert in the

presence of Professor Azam. From Foveau de Courmelles (1890).

C IP

For

Chloe

Acknowledgments Introduction

IX

1

1

The First Fugueur

2

Hysteria or Epilepsy?

31

3

Niches

51

4

Five Questions, Five Answers

Bo

7

Supplements 1 What Ailed Albert?

103

2 The Wandering Jew

113

3 Wandertrieb in Germany

125

Documents 1 Albert's Tale (1872-May 1886)

1 35

2 Albert Observed (June 1886-February 1887)

149

3 Dreams (May 1887-September 1889)

165

4 A Pathogenic Dream (1892)

185

5 Experiments (1888, 1893)

187

6 Epilogue (1907)

192

Notes

195

Bibliography

223

Index

235

Dr. Phillipe Tissie hypnotizing Albert in the presence of Professor Azam

Frontispiece

Fig.

1. Four photographs of Albert in different states

Fig.

2.

Two photographs of Albert, awake and hypnotized

161

Map

i.

Albert's longest journeys

142

Map

2.

The Bordeaux region

164

20

I have to thank the Hannah Foundation for the History of Medicine for a grant that supported Andre LeBlanc's research in Bordeaux, and which cov­ ered incidental expenses. We received help from many individuals in Bor­ deaux itself. Mme Avisseau and Mme Prax, Sous-directrices of the Archives Departmentales de la Gironde, and Olivier Renou, the archivist who helped locate, among other things, the birth certificate of our key patient. M. Savoyac and Dr. Daniel Roy, who helped clear some research paths. Three journalists from Sud-Ouest, the principal Bordeaux newspaper: Michele "Mimi" Sporny, Anne-Celine Auche , and especially Dominique Richard who wrote up our research for a long article which, in turn, paved the way to more contacts. M . Michel Rateau, historian-genealogist-heraldist. Cristophe Dabitche and Mark Eagersall, whose cheerful ambivalence toward their city gave me a better sense of it. The helpful librarians at the Bibliotheque de Medecine et de Pharmacie, Universite de Bordeaux, and the Bibliotheque Municipale de Bordeaux. I also thank Alexander Furrer for his help obtaining materials in the Zentralbibliothek, Zurich . I discussed some of these topics at a seminar in the University of Toronto and in the Eidgenossische Technische Hochschule, Zurich, and in talks at McGill University, the University of California at Los Angeles, the Univer­ sity of British Columbia, Memorial University, Newfoundland, and the Uni­ versity of Calgary. Two early accounts of this work have appeared, one in His­ tory of Psychiatry 7 (1996) : 425-49 and the other, a talk at the Whitney Humanities Center, Yale University, in Modernism/Modernity 3, 2 (1996): 3 1-4 3 It was, however, the Page-Barbour Lecture Committee at the Univer­ sity of Virginia, under the leadership of Allan Megill, who provided the incentive to bring all this material together and a wonderful audience to crit­ icize it. These lectures were given in February 1997· The fourth lecture is a -

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rational reconstruction of the answers I tried to give in Virginia, and which I presented, in March in a more organized form - to an audience that had not asked the questions but was generous with more - as a MillerCom lec­ ture at the University of Illinois, organized by Andrew Pickering. I am grate­ ful to Andre Gombay for help in proofreading French and to Vincent Cullin, who located the 1907 newspaper story that completes my epilogue. Thanks again to everyone, but especially to Andre LeBlanc.

M REFLECTIONS T RA NSIE N T

ON

THE

ME N TA L

REALITY

OF

IL L N E SSE S

These lectures tell about a forgotten epidemic of insanity inaugurated by a mad gas fitter and his doctor, an energetic pioneer in physical education. I intend this story to speak for itself, both as fact and as a parable about men­ tal illness and psychiatry. The strange events that I describe prompt some reflections on transient mental illnesses. Readers who are more keen on the­ ory than adventures may want some advance notice of the use that I make of the story. By_ a "transient mental illness" I mean an illness that appears at a time, in a place, and later fades away. It may spread from place to place and reap­ pear from time to time. It may be selective for social class or gender, prefer­ ring poor women or rich men. I do not mean that it comes and goes in this or that patient, but that this type of madness exists only at certain times and places. The most famous candictate fo r a transient mental illness is hysteria, or at any rate its florid French manifestations toward the end of the nine­ teenth century. Cynics would offer multiple personality today as another transient mental illness and go on to compose a list of other disorders that will prove transient- chronic fatigue syndrome, anorexia, intermittent explosive disorder, or whatever they choose to criticize. Transient mental illnesses provoke banal debates about whether they are "real" or "socially constructed." We need richer tools with which to think than reality or social construction. My theoretical ambitions in these lectures were modest. I did not want to understand reality. I wanted to provide a framework in which to understand the very possibility of transient mental ill­ nesses. The most important contribution here is the metaphor of an ecological niche within which mental illnesses thrive. Such niches require a number of vectors. I emphasize four. One, inevitably, is medical. The illness should 1

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I ntro d u c t i o n

fit into a larger framework of diagnosis, a taxonomy of illness. The most inter­ esting vector is cultural polarity: the illness should be situated between two elements of contemporary culture, one romantic and virtuous, the other vicious and tending to crime. What counts as crime or as virtue is itself a characteristic of the larger society, and the virtues are not fixed for all time: prudence, a virtue for the Protestant bourgeoisie of early modem Europe, had been mere weakness in the feudal era. Then we need a vector of observ­ ability, that the disorder should be visible as disorder, as suffering, as some­ thing to escape. Finally something more familiar: the illness, despite the pain it p roduces� should also provide some release that is not available else­ where in the culture in which it thrives. The lectures are rich in historical anecdote and curious details. But they are not mere stories. They lay out, by an example, the power of the con­ cept of an ecological niche for a transient mental illness. I take for granted that a mental illness - something that counts as madness within a society­ requires both victims and experts. We call these patients and clinicians, but in Lecture 3 I give an example from Greek myths where we have madness, the afflicted, and the experts, though we hesitate to speak of patients and clinicians in any modem sense. The idea of madness is more cross-cultural than the categories of late twentieth-century medicine. Since both victims and experts play such an important part, Lecture I tells a great deal about the first victim and the first doctor in an epidemic of mad travelers that broke out in 1887. The book comes in several parts. There are four Lectures. The first three tell a detailed story, and the fourth discusses matters arising: it reflects on the reality of transient mental illnesses. One cannot, in a set of lectures, include all the rather astonishing historical asides that arise in a true story. Many incidents are relegated to the Notes.They do give references, of course, but they are an integral part of the Lectures, providing a reservoir of information and anecdote that confirms, for me, the simpler statements in the Lectures themselves. There were also some odds and ends. Three Sup­ plements examine other matters arising. Finally there are some translated Documents relating to my star patient and his doctor. Some readers will begin with the Documents, others with the Lectures. It would be by no means foolish to begin with the Notes. Soon after giving the lectures, I found myself rebelling at a curious

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strand in the intellectual life of our times. There is a macabre fascination with the relationship between long-dead lunatics and their long-dead doc­ tors, a fascination that blurs fact and fiction. Pat Barker's trilogy - Regenera­ tion, The Eye in the Door, and The Ghost Road- won the Booker Prize for the third volume, although the first is the best. Its focus is the interaction between William Rivers, anthropologist and doctor of shell shock, and the poet Siegfried Sassoon; many another doctor (Henry Head) and writer (Wil­ fred Owen, Robert Graves) get cameo parts, although the star patient is, I think, fictional. Margaret Atwood's Alias Grace is about the relationship between a mad servant girl who co-murdered her bosses a century and a half ago and the young doctor who goes to study her in the asylum to which she has been con­ signed . The young woman is historical, and so are the Ontario institutions and doctors, although here it is the star doctor who appears to be fictional. These are novels. They deploy the past using recent psychiatric obsessions. Throughout Barker's books post-traumatic stress disorder does the work, though we get some multiple personality in the third volume. In Atwood multiple personality is a permanent question mark; did Grace do the killings in a second personality, or was that personality fabricated not by the good young New England doctor who speaks with her every day but by Jeremiah the peddler who is playing the role of a psychic investigator by the time the quasi-denouement occurs? There is much more fiction, most of it quite tiresome, in which the dead lunatic and the doctor go about their business, but I have j ust men­ tioned the very best of novels from 1995 and 1996. Equally striking is the writ­ ing of cultural history that parallels Barker and Atwood. None is more notable than the work that has Daniel Paul Schreber as star patient and Paul Emil Flechsig as star doctor, with Sigmund Freud as star kibitzer. Schreber, appointed as president or chief justice of the Saxon Supreme Court, was a paranoid schizophrenic who wrote memoirs of himself in an insane asylum. Elias Canetti's Crowds and Power (1978) used these writings to make an amazing comparison between the private madness of Schreber and the pub­ lic madness of Hitler. Both, Canetti thought, were driven by an insane sense of the potential of power. Canetti was theoretical. More recently there has been so much detailed examination of the life and times of Schreber that I am inclined to say that we know "everything" about him, especially thanks

4

Intro d u c t i o n

to the passionate research of William Niederland, The Schreber Case: Psy­ choanalytic Profile of a Paranoid Personality (i984), and Zvi Lothane, In Defense of Schreber: Soul Murder and Psychiatry (i992). Thanks to plenteous photographs obtained by Lothane, we even know what everyone in the Schreber story looked like. Louis Sass, in The Paradoxes of Delusion: Wittgenstein, Schreber, and the Schizophrenic Mind (i995), has used Schre­ ber to understand schizophrenia from within, to see the schizophrenic as solipsist, and thereby to comprehend Wittgenstein's battle with solipsism, if not with schizophrenia itself. And let us not forget that Thomas Bernhard's one-sentence novella, Wittgenstein's Nephew, was a tour de force using j ust the themes that Sass took up. Bernhard, superb artist, was not quite writing about our Ludwig Wittgenstein, and certainly not about Schreber, but there in the book is the solipsist in the garden of the Viennese asylum, Wittgen­ stein's nephew, looking at the sun. Sass took Schreber inward. Eric Santner's My Own Private Gennany: Daniel Paul Schreber's Secret History of Moder­ nity (i996) goes so far inside that it uncovers, in the mad mind of Schreber, the modern world and the makings of the German disaster. I read most of these works after lecturing about a bicycling physician and his patient, a demented gas fitter who obsessively and uncontrollably takes off for days or months or years, often walking 40 miles a day, losing his papers, his identity, but not his demand to go, go, go. So I found this obses­ sion with mad individuals and their doctors quite unnerving. What kind of understanding do we strive for, in the fact and fiction of madness? What type of escape is this, in which we pretend to understand our world in terms of dead lunatics and their equally deaa and possibly equally mad doctors? I even saw a dreadful symmetry. Barker, in fiction, doing the truly famous doc­ tor and patient; Atwood, in fiction, doing the truly obscure doctor and patient. Canetti through Santner writing fact, not fiction, about the now famous patient Schreber and his doctors, in order to tell a story about the whole of the modern world, plus Hitler and Wittgenstein. And I, in minia­ ture, doing a factual account of a truly obscure patient and equally obscure doctor. The symmetry, of course, is that the Canadian authors, whether in fiction or in fact, prefer to write about obscure provincials. But what are we all doing? Are we engaged in more than voyeurism? It was only when I turned back to read some new histories of psychia­ try, or of branches of that discipline, that I could put my discomfort aside. For

I n t r o d u c t io n

5

the histories of medicine to which by chance I turned had so little to say about the patients, the real people. We desperately need the great narrative scope of the old French case histories, even of Freud himself, to get a glimpse of how our fellow men and women break up, in a time and at a place. The novelists give us the sense of the time and the place in which mad­ ness is both intelligible and yet insane. That too is done by the historical work of Lothane and Niederland and the larger placings, albeit with agen­ das, of Sass or Santner. According to Karl Jaspers, Schreber's written-down thoughts were absolutely impermeable, unintelligible, the perfect exemplar of how madness cannot be accessed. But by now they are, in a way, all too intelligible. They are invested not with too few meanings but too many. That is a real danger, to forget we are talking about the mad judge Schreber, who, even after he got better and went home, then got worse and died in an asy1 um. We can get so close, and so inside, that we lose j ust as much touch with the patient as do those historians of psychiatry. The novelists provide a bet­ ter model, for they give us suffering and comedy and avoid profundity. One reader of my story wanted more history- of the politics of psychi­ atry, for example, and how it fitted into nineteenth-century French politics. Instead I added more about buildings, more about the sense of being in provincial, closed-in Bordeaux, where Albert went mad. I am no novelist, but I hope to have invited the reader into the mean dark streets of a town that suffocates under its own pride or into the spacious cloister of the hospital where my compulsive walker found a safe place. I talk more about my doc­ tor's enthusiasm for cycling than the latest news from Paris. I came to realize that I was less a voyeur than a companion, and that this was the right expe­ rience with which to frame the theoretical questions and concepts which, at another level, are the topic of these lectures.

I

t all began "one morning last July when we noticed a young man of twenty-six crying in his bed in Dr. Pitres's ward. He had just come from a long journey on foot and was exhausted, but that was not the cause of his tears. He wept because he could not prevent himself from departing on a trip when the need took him; he deserted family, work, and daily life to walk as fast as he could, straight ahead, sometimes doing 70 kilometers a day on foot, until in the end he would be arrested for vagrancy and thrown in prison."1 Thus begins our story in a ward in the ancient Bordeaux hospital of Saint-Andre.2 The young man's name was Albert; he was an occasional emplo).' ee of the local g as company, and the first fugueur. He became noto­ rious for his extraordinary expeditions to Algeria, Moscow, Constantinople. He traveled obsessively, bewitched, often without identity papers and some­ times without identity, n �t knowing who he was or why he travelled, and knowing only where he was going next. When he "came to" he had little rec­ ollection of where he had been, but under hypnosis he would recall lost weekends or lost years. Medical reports of Albert set off a small epidemic of compulsive mad voyagers whose epicenter was Bordeaux, but which soon spread t� Paris, all 7

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France, Italy, and, later, Germany and Russia. Fugue became a medical dis­ order in its own right, with earthy labels like Wandertrieb and suitably Lati­ nate or Greek-sounding ones such as automatisme ambulatoire, determin­ ismo ambulatorio, dromomania, and poriomanie. Fugues, that is to say strange and unexpected trips, often in states of obscured consciousness, have been known forever, but only in 1887, with the publication of a thesis for the f degree of doctor of medicine, di � mad travel become a specific, diagnosable type of insanity. Albert's str� nge tale is one of picaresque adventure and bitter pathos, but why tell it now? Because we are besieged by mental illnesses, more neurotic than psychotic, and we wonder which of them are affectations, cultural arti­ facts, clinician-enhanced, or copycat syndromes, and which ones are, as we briefly and obscurely put it, real. We are profoundly confused about an entire group of mental disorders, feeling that their symptoms are both nur­ tured and natural, both moral and neurological. Is PMS, premenstrual syndrome, a disorder or something that a pre­ dominantly male profession of psychiatrists has written into its nosology to deal with irritable and irritating female patients? Fidgety children have been with us forever; then came hyperactivity; next, attention deficit; at present attention deficit hyperactivity disorder, for which the steroid Ritalin is pre­ scribed . Is that a real mental disorder? Or is it an artifact of psychiatry demanded by a culture that wants to medicalize every annoyance that trou­ bles parents, teachers, bus drivers, and all the other powers that be? Anorexia and bulimia cause immense distress to patients and their families. The suf­ fering is manifest, but are we talking about behavior that is produced by stereotypes of female beauty, combined with a way of rebelling against par­ ents, or are we talking about a "real mental disorder"? Is multiple personality disorder, now named dissociative identity disor­ der, "a true psychiatric entity and a true disorder" afflicting perhaps 5 percent of college students and also 5 percent of admissions to any acute care adult psychiatric in-patient unit?3 Or is it a a self-indulgent way to express genuine and profound unease that has been cultivated by clinicians and the media, but which has no medical content at all? Are we to take seriously antisocial personality disorder or intermittent explosive disorder, blaming a good deal of violent crime on these psychiatric entities? Or are we to see these as part of the apparatus of forensics by which ·

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justice and medicine conspire to define and control the criminal element, all the while burying systemic poverty as a critical ingredient in crime? It is not only what used to be called neuroses whose reality is called in question. Schizophrenia, or rather "the group of schizophrenias," was first named in Switzerland in the first decade of the twentieth century. It was long a popular diagnosis. Yet it has been withering away. Not only have the symp­ toms been ameliorated by several generations of psychotropic drugs, but the proportion of actual diagnoses has declined markedly in a large number of medical jurisdictions. Most psychiatrists who try to help schizophrenics speak of it as a dreadful disorder that strikes young adults (among others) and destroys not only the patients but their families and friends. Yet it has been repeatedly argued that there is no such entity, that it is a "scientific delu­ sion."4 Symptoms aplenty, yes, but different congeries of symptoms in differ­ ent decades of this century, with no determinate medical entity from which they emanate. I happen not to be a skeptic about schizophrenia. My focus in these lec­ tures is not on psychoses but on those disorders that were once called neu­ roses. That group of medical entities may be about to explode. The New York Times Tuesday "Science Times" of 4 February 1997 bore the headline, "Quirks, Oddities May Be Illnesses." The occasion was a new book, Shadow Syndromes, featuring subclinical autism, depression, and the like . 5 People exhibit shadow syndromes when they satisfy part of a checklist for a disorder but not enough to diagnose that disorder; on the other hand, there is "clini­ cally significant distress or dysfunction." Such proposals do not come from a lone psychiatrist and his coauthor. Plenty of support for the new diagnoses is cited by the newspaper, which includes favorable comments by, among others, Robert Spitzer, who directed the teams that produced the successive official diagnostic manuals of the American Psychiatric Association - the Diagnostic and Statistical Manual, DSM III (1980), DSM III-R (1987), and DSM N (1994). A new form of the reality question arises. Many people are, to use some of the popular adjectives mentioned by the Times, "weird," "odd ducks," and "nerdy." Some of us were uncoordinated in sports as children and were, or are, not very good at making new friends. Are we suffering from an illness (a real illness!), in this case subclinical autism? With multiple personality, some skeptics urge that unhappy people have evolved symptoms in concert

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with their doctors and the media. With shadow syndromes, there is no ques­ tion (yet) of doctors or media cultivating loners and ball-fumblers; that behavior is real enough, as we inveterate lonesome ball-fumblers know to our cost, hut are we to be conceptualized as ill? Above all, are we to be treated as ill by the experts, with their array of medications, therapy, and bills? I do not predict a quick answer to that question . Passions run high about old questions and will run high about new ones. Ideologies are intense. In play are feminism, Marxism, and scientism; psy­ chiatry and antipsychiatry. Lobbying is vigorous, whether in the committees that settle the approved entries for official diagnostic manuals or in groups of patients and their families that try to take some control over their problems. Lurking behind these activities, sometimes sedate, sometimes frenzied, is a nagging question. What counts as evidence that a psychiatric disorder is legitimate, natural, real, an entity in its own right? Ludwig Wittgenstein said that in psychology there are experimental methods and conceptual confusion .6 We have more than that for the mental illnesses. We have the clinical methods of medicine, psychiatry, psychology; we have the innumerable variants of and deviations from psychoanalysis; we have systems of self-help, group help, and counselors including priests and gurus; we have the statistical methods of epidemiology and population genetics; we have the experimental methods of biochemistry, neurology, pathology, and molecular biology; we have the theoretical modeling of cog­ nitive science; and we have conceptual confusion . Perhaps all our problems will be erased when we have enough objective scientific knowledge. I have another view. We do have a limitless reservoir of ignorance, but we also have conceptual confusions that new knowledge sel­ dom helps relieve. There are a number of reasons for th is, but I am especially impressed by the way that scientific knowledge about ourselves - the mere belief system- changes how we think of ourselves, the possibilities that are open to us, the kinds of people that we take ourselves and our fellows to be. Knowledge interacts with us and with a larger body of practice and ordinary life. This generates socially permissible combinations of symptoms and dis­ ease entities. We often express our malaise about this phenomenon, wh ich we do not correctly identify, by asking whether certain disorders or their manifestations are real . The first chapter of my recent book about multiple personality was

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titled "Is It Real?" "I am not going to answer that question," I wrote; "I hope that no one who reads this book will end up wanting to ask exactly that ques­ tion."7 Vain hope! Time and again people have taken me aside and quietly asked what I actually believe: Is multiple personality real or not? There is, to be sure, a special skepticism about multiples. My interroga­ tors tend to hope that I will side with the angels (or rather, whichever side they believe the angels to be on). They hope I will say that there definitely is such an illness, whose symptoms I describe with great precision and with such a depth of sympathy. Or they hope that I will say that there is no such illness, that the phenomena I describe so ironically are part of a "social con­ struction." Or the disorder is "iatrogenic" - caused by doctors - or, inge­ . niously, "doxogenic " - caused by a bel ief system cultivated.by therapists and the media. s People are not going to stop using the word real or its co-workers such as true in connection with controversial mental problems. Reasons for this range from finance to responsibility, from semantic theory to scientific meta­ physics. Health insurance should pay only for real mental illnesses, right? Responsibility is the crux. We have a profoundly moral attitude to disease. If something is a real disease, you are not responsible for it or are responsible only insofar as you engaged in vice that brought on the disease. Sex, drink, and idleness are typical vices. But if you need costly hip-replacement surgery because you continued playing boyhood games such as basketball into mid­ dle age, you are not blamed or held responsible; this is because in our world continued youthful activity is a virtue. In the case of mental illness, respon­ sibility may be diminished or removed altogether if the illness is a real one. And the names for real illnesses have obj ective, individuated referents; sci­ entific metaphysics and popular science alike demand that the referent is biochemical, neurological, organic, something localized in the body that could in principle be isolated in the laboratory. But these are matters for Lecture 4. Analytic philosophers like myself are trained to make distinctions and clarify ideas. We like to think that this helps to remove confusion. I believe that most important conceptual difficulties are rather unyielding. This is because they result from some fundamental incoherence in the underlying organization of our ideas - ideas that we will not give up partly because they are essential to the ways in which we do think. Reality and responsibility- like reference, science, and the body- are ·

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rather grand examples of organizing concepts. No amount of analysis makes deep confusion evaporate; no amount of heated debate boils it off. But there are things we can do. One is to examine in some detail a manageable exam­ ple in which many of the ingredients of the confusion are plainly on view. Enter Albert. Enter the fugue epidemic of the 1890s. It is elegantly constrained. We know exactly where and when the diag­ nosis of fugue begins, and we can watch it peter out. Here we have one diag­ nosis that is extinct and yet, in certain respects, curiously up-to-date . It resembles recent epidemics in that it is important only at a time, in a locale, it has a vogue, spreads, decays, and the world passes on to next year's afflic­ tion. I ought to say that my example is not entirely antiquarian. Dissociative fugue is a diagnosis in the handbooks of the 1990s, in the manuals- of both the American Psychiatric Association and of the World Health Organiza­ tion.9 Even there hangs a tale, for especially in America fugue is a grandfa­ thered diagnosis. That is to say, it is kept on the books partly because it has been on the books1 and also for certain reasons of political rhetoric that I mention in Lecture + The diagnosis is never or almost never made and yet is listed as a possible diagnosis as if it were a bit like measles, and very much like depersonalization disorderi which you can_j_!lst "have.'' After I have told you enough about cases of fugue, you will begin to feel torn. Yes, you will be inclined to say, these people did suffer from a "true psy­ chiatric disorder" (perhaps more than one). The doctors of the day used a diagnosis that did fit their cases; fugue was a viable entity. Yet at the same time the phenomenon is steeped in the social circumstances of the day. We are tempted to say that whatever ailed these patients (and they were ailing!), the manifestations, the marks of their illness, were entirely socially condi­ · tioned. Here, then, is my method: I tell you a true story about a disorder of which you have never heard. It is a sufficiently gripping story that you will attend to it and take in its salient features very quickly. Yet you will realize that this more or less "dead" disorder is a vignette of a type of problem that vexes us today. Why take an old case rather than a present one? Because par­ tisan reactions will not arise immediately; when they begin to surface, you may reflect on why they do appear for so dusty and obscure a chain of events long ago, about which we ought to be indifferent. Fugue is a happy choice because it is just plain interesting in its own right-fascinating to me, and I hope to you, in part because travel has

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become so integral a part of the learned world. Throughout this century the Page-Barbour Lectures have invited travelers from afar to tell Virginians, if not of wonders, at least of "some fresh aspect or aspects of the department of thought," as· the deed of trust puts it. Each person in the audience takes for granted that a vacation may, and often will, involve a trip. Albert's own trips are so striking that I sketch a few of them here. Albert's own account, as taken down by his doctor, is the first of the documents that follow the lectures. Fugue itself conveniently illustrates many social facets of mental illness that are by now rather old hat. It is highly gender-sp ecific. It is class-specific. It is directly involved with systems of social control, and I do not mean abstractions about power and knowledg e. I � ean the police and the military. One is hard-pressed to say who has the greater role in defining, in realizing, the disorder as a correct diagnosis - the class of patients or the class of physi­ cians. Fugue is closely connected to the late nineteenth-century mental ill­ ness that has, in the past two decades, attracted most attention by cultural historians: hysteria. That standing conundrum, hypnotism, plays its role in fugue. There is a preenactment of one of today's embarrassments for affluent cities, the homeless. Anti-Semitism rears its conventional head, for who is the archetypal fugueur but the Wandering Jew? I take up that issue in Sup­ plement 2. These matters strike familiar chords, albeit in somewhat novel arrange­ ments. I prefer to emphasize another idea. It uses as metaphor a notion that became fashionable in another field some time ago: the ecological niche. We are struck by the phenomenon that some types of mental illness and some arrangements of symptoms are central at some times and places and absent in others, even in the history of one fairly continuous culture. These are the ones that I call transient, not in the sense that they come and go in the life of a single person, but that they exist only at a time and a place. I argue that one fruitful idea for understanding transient mental illness is the ecological niche, not j ust social, not j ust medical, not just coming from the patient, not just from the doctors, but from the concatenation of an extraordinarily large number of diverse types of elements which for a moment provide a stable home for certain types of manifestation of illness. Now, however, I ask you to be content with an introductory story about a young gas fitter of Bordeaux. We first hear of him in a thesis with an unusu­ ally romantic title: Les Alienes voyageurs.10 We may fear already that the

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author, the by no means young medical student Philippe Tissie (1852-1935), liked a good yarn. Tissie would not pass as your average intern in any hospi­ tal, at any time. When he first set eyes on Albert he was thirty-three years old. He had been orphaned at fourteen, had worked twelve hours a night as a bookkeeper's clerk at a Toulouse railway station.11 During the day he took music classes at the local conservatory. When he turned sixteen he moved up to a day job as a delivery man, all the while going to night school . After providing for the education of two younger sisters by savings from such menial work, he got his big break when on his twenty-third birthday he shipped out of Bordeaux on a steamer, the Niger, on the Bordeaux-Senegal run. 12 He worked as a supercargo's clerk.13 The ship's doctor took a shine to him and after a couple of years urged him to apply for a post as underlibrar­ ian to the medical faculty in Bordeaux. He got the job, completed his bac­ calaureat in the sciences, and by 1886 finally had fulfilled all qualifications for the medical degree except his thesis. He was working in the ward of Albert Pitres, a hotshot neurologist who had been a student of Charcot's in Paris, and who in 1881 had become professor in Bordeaux at the age of thirty­ three, the age when Tissie was still completing his studies. In 1886 Pitres was giving lectures on hypnotism and hysteria, and it was no surprise that Albert was assigned to his ward. So Albert was there for Philippe Tissie to describe in his thesis. B ut so were a great many other patients. About sixty were assigned to a ward. Tissie did not choose Albert by chance. The man and h is doctor were made for each other, opposite but parallel . Opposite: Albert was barely lettered, able to read, but he could hardly write. Tissie was always at his letters, even as an adolescent doing full-time menial jobs. Where Albert was the victim of impulse and uncontrollable dri­ ves, Tissie was a model of goal-directed planning and achievement. But par­ allel: Tissie, like Albert, was always close to movement, keeping books at night in the train station, that center of all movement, or delivering, or on the good ship Niger whose very name is redolent of colonial travel and adventure in darkest Africa. There is more to it than that. The only thing I know about Tissie's boy­ hood is that early on he heard of the latest wonder, the velocipede, "the won­ derful invention that needs neither a horse nor a carriage." One day in the early sixties the great Leotard came through town on his way to Toulouse: Leotard, the man-bird, the greatest trapeze artist of the day, and a pioneer of

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cycl ing (and, yes, the man after whom that athletic garment, the leotard, is named). All the children turned out to watch him whiz by. Tissie recalled how "he went so quickly, on two great wheels, I heard the grinding of metal and wood. I had seen a velocipede!" His father had the local wheelwright make a wooden tricycle for h is son, and the cycle remained a love of Tissie's l ife and a part of h is profession later on.14 When Albert came to Tissie's notice in 1886, the bicycle had just become the middle-class sporting instrument of choice; indeed, in France cycling was the very first popular, that is, nonaristocratic, sport.1 5 A few dates sum up the story. In the early 1880s the Safety bicycle became generally available - the prototype of the modem bicycle with two equal-sized wheels and driven by pedals and a chain. The free wheel was invented in 1881. The first long-running magazine devoted to the sport, Le Sport Velocipedique, commenced in 1880.16 In 1881 a national federation of cycling clubs was established, Union Velocipedique de France. There had been racetracks for horses forever. In 1884 the first track for (human) runners was built in Paris. The first velodrome preceded it, in Paris, in 1879. Montpellier built one in 1885, and Bordeaux immediately followed. There had been lon g-distance cycle races for quite some time: Paris-Rauen on 7 November 1869. The Paris-Bordeaux race did not begin until 1891, but it was established as the first of the "classiques": one-day road races on the professional cycling calendar. In that year inflatable rubber tires came on the market in France. In January 1890 the Touring Club de France was founded - for cyclists. By the end of the decade it had 73,000 subscribers, thirty volumes in the series Sites et Monuments de France, and numerous manuals rating local hotels and mechanics. When you think of Bordeaux, you think of wine, and perhaps of a town that has j ust overcome its ruination, the phylloxera louse that destroyed the vines. That began in 1863 but had been solved by Albert's time, thanks to grafting the old vines onto Cal ifornia stock. If you are learned, you recall that j ust as Albert was checking into the hospital, Emile Durkheim was moving to Bordeaux to begin the course of lectures that would invent modem soci­ ology. B ut you did not know that Bordeaux was the absolute center of activ­ ity for the first popular French sport. Albert's doctor soon became the official doctor of the Veloce-Club de Bordeaux, and he was writing columns for its magazine, Le Veloce-Sport, which were collected into a Cyclists' Guide for

16

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Training, Racing, and Tourism.17 He was one of the architects of the Bor­ deaux-Paris race, and there he is, in charge, in the photograph at the starting line. And apparently he scandalized his colleagues and the good citizens of Bordeaux by making house calls on a bicycle.18 I fancy that my newfound friend was the first physician in the world who pedaled on his rounds. I shall spare you Tissie's later history as a leader in physical education, a rather astonishing story but one far too complicated for us. Physical educa­ tion was one battleground for the reformation of France, its youth, its edu­ cation, its glory. Those who like simplification may find that those on one side -Tissie's - happened to be Dreyfusards. We who have nothing to do with France, or physical education, or a long-dead scandal, have inherited the wind in the form of the Olympic Games, pushed by Coubertin and other anti-Dreyfusards over the anguished protests of men like Tissie, who did not much like competitive sport on the English model and who favored rational and moderate exercise , aerobics, Swedish gymnastics, cycling, and long walks. But all that, except for the long walks, is quite another story. Histories of French physical education are a bit bemused when they come to Tissie's medical thesis; they suppose that Tissie studied Albert precisely because the man was able to travel such prodigious distances on foot, a veritable instance of training to excess. 19 The historians of physical education have lost touch with Tissie's psy­ chiatric practice. Historians of medicine, on the other hand, have now amply described the political schisms that divided the French medical profession, French alienists in particular, and French society in general. In Rewriting the Soul I observe how useful multiple personality was for those doctors who were anticlerical and ill disposed to the idea of a unitary immortal transcen­ dental metaphysical (etc.) soul . Those same doctors were usually positivist, in the strong and proper French sense of the word, derived from Auguste Comte, who invented it; that is, opposed to theory in favor of experiment and observation, opposed to invisible entities, opposed to what they called meta­ physics, and opposed even to the idea of causation, preferring a rather Humean notion of constant conjunction and in general being much impressed by the Scottish idea of the association of ideas as a guide to psy­ chology. In addition, the doctors who figure in the story of multiple person­ ality were mostly republican, that is, deeply opposed to any restoration of the monarchy. Republicanism, positivism, and anticlericalism usually went hand in hand.

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H istorians of medicine have not yet, however, sufficiently connected this trio of attitudes to other aspects of French life, for example, physical educa­ tion. The great physical education movements were rich in political signifi­ cance. Thus in January 1890 a Ligue Nationale pour }'Education Physique was founded in Paris by the anarchist communard Paschal Grousset, who having been exiled in England was determined on his return to introduce competitive sports in a systematic way for the improvement of French youths.20 Only a couple of months later in 1890 Tissie founded the Ligue Girondin pour l'Education Physique. Gironde is the department in which Bordeaux is situated. Was Tissie's league a provincial society analogous to the national one but smaller? Not at all. It was the only significant provincial society for gymnastics in France, and in many ways it played a greater part in French physical education than the national league. Tissie is now lauded in physical education circles as a pioneer of regionalism, which has become an important theme in late twentieth-century France. He was far more than that. He detested statism, centralism, Jacobinism, Napoleon, and most things that came from Paris. Girondin did not just denote a region, La Gironde. It meant politics. Tissie's Girondin League was founded early in 1890. Now 1889 was the centenary of the Revolution, the year of the great World's Fair in Paris, the year the Eiffel Tower was constructed. Soon afterward Bordeaux began to build what is still its own tallest monument, the Monument to the Girondins.2 1 The Girondins: that was the name later given to the club of men who clustered around Brissot, and who in 1789 stood for change with moderation. Many of its members were from the Bordeaux region. The Girondins lost out to Robespierre and the radical Jacobin club. In one of the most dramatized scenes of the Terror, some twenty went to the guillotine. Thus the erection of this rather astonishing monument, glowing in the green of weathered copper, surrounded by les chevaux des Girondins-steeds galloping through spouting water - was commenced in 1894 as a memorial to moderation and provincial integrity, against the folly of the capital. The year i889, the centennial of the Revolution, was by no means tranquil. In the spring the populist General Boulanger was generally supposed to be about to march on the Elysee, the presidential residence, in order to abolish the Third Republic and establish a popular dictatorship that would consult the people with occasional plebiscites. zz The coup d'etat did not take place, but it is still widely believed to have been a very near thing. I do not wish to dwell

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on political history, but we should see Tissie, founding the Ligue Girondin, as engaged in a deeply political act, whose meaning was plain for all to see. It meant the independent moderation which was part of the self-image of Bordeaux. Moderation ran to all things. When Tissie's professor, Albert Pitres, pub­ lished his treatise on hypnotism and hysteria, one of his students reviewed the book. "The hysteria of the Saint-Andre Hospital is," wrote the disciple, "in comparison to the grande hysterie of the Salpetriere [Charcot's hospital in Paris] a petite hysterie."23 The same goes for the political views of the members of the medical profession who concern us. The great positivism, republicanism, and anticlericalism of their Parisian colleagues was repro­ duced, in Bordeaux, as a modest positivism, a moderate republicanism, a gentle anticlericalism. Albert, employee of gas companies, was not involved in these grand schemes. His fantasies were of faraway places; I doubt that he noticed what engaged his own doctor, let alone the political upheavals and battles going on in France. Before saying more about him, I should first enter a caveat. The interest in Albert is not about what really happened in the course of his life, or what was the cause of his curious behavior. He matters to my story because he is the first in a line of fugueurs. He and his doctors establish, in a hyperbolic way, the possibility of fugue as a diagnosis in its own right. Everything I am about to describe could be fantasy. Everything could be what in the trade is called folie a deux, half madness, half folly, produced by the interaction of doctor and patient. Such folly could still inaugurate an epidemic. And folly it may be, for after a brief account of Albert's parental antecedents, Tissie launched into a bizarre tale. Worse, although the tale was told in Albert's own voice, as if he were reciting it on the couch, we know that nearly all the facts were obtained from Albert under suggestion and hyp­ nosis, perhaps the least reliable sources of testimony known to the human race. Document i below is Tissie's first report of Albert's travels. We read what are supposed to be Albert's words, yet Albert must have spoken with an extremely heavy Gascon accent, now the preserve of great-grandfathers. Hypnotism is suspicious, but we have, nevertheless, some controls. Quite a number of doctors had a go at Albert. That is not in itself a ground for verisimilitude, but one may be impressed by a figure in the French mili-

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tary establishment. Men from the medical corps, especially one just pro­ moted to the most important French military hospital, Val de Grace, and well trained in the detection of malingering, ought to have some skepticism in their bones. Such a one, Emile Duponchel , had been garrisoned in Bor­ deaux before his promotion and helped debrief Albert. He describes how Albert "is easily hypnotizable and readily submits to suggestions. In hypnotic sleep he recalls a certain number of details of his adventurous life, which had been forgotten during his waking state. It was thus that we were able, lit­ tle by little-also by writing to French consuls abroad and by consulting the civil and military authorities at home - to reconstitute with commendable patience and by means of indubitable external proofs, the successive episodes of his romantic existence."24 There is a drawing of Albert in Tissie's thesis. There are four pho­ tographs from Pitres's textbook of 1891. These show Albert in four states: two normal , front and side, then hypnotized, and then fugueur (fig. 1). Beware, however, for I suspect that these photographs may have been taken at one sit­ ting, perhaps even in the photographer's studio.25 These shots show how Albert was supposed to look in each of his states. It was urged in many quar­ ters that photography introduced true objectivity into science. No longer did we have to rely on artist's impressions or verbal reports. Caveat emptor! Louis Vivet, the very first multiple personality in history- that is, with more than two distinct and diagnosed personalities-was photographed in some ten supposedly distinct personality states, representing different stages of his life, but the photos were taken in at most two sittings, and mere changes in pos­ ture represent hypnotic suggestion.26 Jean-Albert Dadas was born on 10 May 1860, son of Romain Dadas and Marie Dumeur.27 Marie died of pneumonia at age fifty, in 1877. Albert always remained devoted to her memory, in a sentimental, or even maudlin, way. 2s The men in the family worked for gas companies. The father Romain had once had a little money but lost or squandered it. He died of softening of the brain at age sixty-one, in 1881. Father Dadas was first of all a hypochon­ driac-you had only to tell him he looked poorly and he would go home to bed, complaining of pains. As he aged, "he devoted himself, in excess, to the pleasures of sex; he frequently left home; then he became senile. Symptoms of general paralysis." Very probably he was syphilitic. One son had gone up in the world and managed a gas factory in the Midi, but he died of menin-

PLANCBE I.

FIG.

3·

Fie,.

2.

F1G.

4·

Fig. 1. Four photographs of Albert in different states by F. Panajou, director of photography at the Bordeaux Faculty of Medicine. From Pitres (1891), vol. 2.

Top: In his normal state. Bottom left: At the end of an attack of "ambulatory automatism." Bottom right: When hypnotized.

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.21

gitis at the age of thirty-five. A second, also hypochondriac, worked in town, once again for the gas company, but suffered from headaches. He died in 1892. Albert's sister was in good health, married to another gas worker. These were solid artisans, respectable, seldom without work when they needed it, loyal to their employer who in turn took patronal responsibility for their wel­ fare. Albert fell from a tree at age eight and had a concussion, with vomiting and subsequent migraine. From the very start we can read this story as a case of childhood head injury, but let me first tell it Tissie's way. Albert was apprenticed to a manufacturer of gas equipment at the age of twelve. He worked well and then disappeared. His brother found him in a nearby town helping a traveling umbrella salesman. Tapped on the shoulder, he acted as if he were awaking from a deep sleep, groggy and confused, astonished to find himself where he was, carting umbrellas. Then began a standard pattern. He was given 100 francs to obtain coke for the gas company and woke up on the train with a ticket to Paris. How much was 100 francs? When young Tissie worked nights in the train station, he was paid 30 francs a month; when he was underlibrarian for the medical faculty, his annual salary was 1,200 francs. So 100 francs was real money, but not a lot of money. At any rate, Albert was found sleeping on a bench at the Gare d'Orleans in Paris, kept in custody for a fortnight, and then sent back to his family. But his employer wanted the 100 francs from his family, so Albert stopped en route and worked in domestic service for some months, saving up before he returned home. That was how it went. Overhearing a place-name, Albert felt compelled to set out. At some point he was astonished at where he had got to, often des­ titute, sometimes arrested. He tried to find work, did odd jobs, scrounged, and managed to get home, often under conditions of terrible hardship. Thus once someone spoke of Marseille; when he got there, people talked of Africa, so he took ship for Algeria, where he had numerous adventures and, in some desperate place, was counseled by a Zouave to go home. He obtained tips for trifling services, implored a ship's captain, and went back to France, scrubbing pots in the galley. He arrived in Aix at harvesttime, was arrested in the fields as a transient agricultural laborer without papers, and did a month's forced labor. H is major trips began when he voluntarily enlisted in the 127th Infantry

22

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Regiment, where he served as a cook. He encouraged a chance-met child­ hood friend to join up, but the friend was posted to the 16th Dragoons. Since the two chums could not billet together, both deserted, and then Albert led the march through bitterest winter, Belgium, Holland. Very early on the friend died from cold, hunger, but especially exhaustion. Extensive wandering in Germany, to N uremburg, then down the Danube. By Linz, Albert had lost his papers and was imprisoned for eight days. The prison doctor saw he was very ill and had him released. On to Vienna where he got work in the gas factory - and yes, we have letters from the manager to prove it. After some more travel he learned of a general amnesty for French deserters and made his way home. Although besieged by headaches and diarrhea, he soon headed out again. One is struck, in reading these tales of flight, how easy it was to get around Europe a century ago, even if travel was not without its perils. Albert's standard modus operandi was, when he found himself in a strange place, to report to the French consul, who would give him just enough to get home on the train, fourth class. Albert would then hear a chance place­ name, leading him to head in the opposite direction. He also begged from Frenchmen in foreign parts. Students would take up a collection for him, a village populated by descendants of emigre Huguenots was always kind to Frenchmen, and there was sometimes a Societe Fran�aise to give him some pennies and a loaf of bread. His greatest flight began with his politely taking his uniform and military equipment to the police office in Mons and then heading east- Prague, Berlin, Posen, Moscow. En route, passing through East Prussia, he was attacked by a vicious dog while begging at a manor owned by a Frenchman. The scars were permanent; in the short run the owner paid for two weeks in the hospital. In Moscow a superintendent of police said, "I know who you are!" - much to Albert's delight. Except he was arrested as a known nihilist, in the great sweep following the assassination of the czar, 13 March 1881. He spent three months in prison with all the other nihilists. The prisoners were separated into three groups, one to be hung, one to Siberia, and the rest to be walked out of Russia, to Turkey. The story of the exodus - at least in Tis­ sie's hands - is truly vivid, the Cossack guards, the accompanying Gypsies, "unbelievably filthy," who are starving and who copulate on the fields with the other deportees for a scrap of bread or sip of brandy. Albert is chaste,

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despite valiant attempts at seduction to cheer the lad up, after which he sat­ isfies himself "in his usual way." I did not mention that according to the case report, by the time he was twenty-six, Albert had had sexual intercourse only three times in his life, the first time in Vienna, but that he was an "inveter­ ate masturbator." He made it to Constantinople, where an ever-obliging French consul gave him the funds to get to Vienna, where he went to work once again with the gas company. Fantasy? The fixed points, the consul, the former employer, certain French people who helped him, were confirmed. Th e arrest, the forced march from Moscow to the border? Well, anyone who read the newspapers would have known about the police rounding up nihilists, even the propor­ tions that were executed, sent to S iberia, or exiled. Albert did not need to go to Moscow to overhear this story. He had learned to read in the army and preferred to read reports of distant parts of the world. The events in Moscow were the talk of Europe, so he could have composed his adventure entirely in his head. I confess I believe him; certainly the skeptical Duponchel did. There is plenty more bizarre detail on this trip, but the upshot was that Albert finally reported back to his regiment and was found guilty of deser­ tion. He was sentenced to three years hard labor in Algeria. He worked well, but the shaving of his head caused him unbearable pain; he spent much of the time in the hospital. He was released from the army for good conduct and because he had a damaged eardrum. He returned to Bordeaux to work for the gas company, fell in love, became engaged . . . and disappeared on 18 June 1885. He turned up early in September in Verdun, having no idea what had happened during that time. His girlfriend had meanwhile had the sense to tell him never to speak to her again. On 9 December he was given a sort of welfare ticket home and on 17 January 1886 entered Saint-Andre. He was transferred to Pitres's ward on 24 February. The next day, when Pitres and his assistants went to examine him, he had disappeared . . . but he now spent most of his time in hospices until his return to Bordeaux, 3 May 1886. What was Albert like? I plunge into speculations about Albert and what ailed him in Supplement 1. For the present let us content ourselves with the simplest facts. In his normal state, at home, in the factory, or as a cook in the army, he was a good worker, timid, respectful, shy with women. He never drank and when he was on a fugue had a particular hostility to alcohol. At

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home he would have a regular and uneventful life. Then would come about three days of severe headaches, anxiety, sweats, insomnia, masturbation five or six times a night, and then - he would set out. Usually a fugue was not exactly unplanned. He would get a little money together and some identity papers. At the last moment he would drink several glasses of water or stop at a bar and order a couple of glasses of barley water (orgeat) or some other soft drink. Then off he would go. Over and over again he would lose h is identity papers.29 It is hard not to think that he sometimes wanted to lose his identity. Yet late in his journeys he knew perfectly well who he was and how to get help. Overall, there is a curious mixed quality to his trips. There is no doubt that he got into a terri­ ble state before taking off, and it can truly be said that the need to go over­ powered him. Nevertheless he had very variable states of consciousness on the road, sometimes making quite deliberate choices. His reaction when the fate of the nihilists was being decided: Great, the czar will send me to Siberia, beyond my wildest dreams! His nocturnal masturbation fantasies often involved a woman he had seen during the day, with a picture of the two of them setting out on a great trip together. This man hated the fact that his "imperious need to travel," as Tissie called it, prevented him from living a normal life. But he also wanted to travel and from childhood had been fas­ cinated by stories of faraway places. People did not notice Albert much on his travels. Even though he slept rough, he was very clean, taking care to wash in streams and scraping the mud off his shoes. When he "came to," he usually would have no idea of how he had arrived where he was. Later, he might have a general idea of where he had been, with some casual and to my mind rather suspicious touristic details about the sights on the way, but no memory for any specific happenings, such as the dog bite. "How did you get that mark on your arm?" "Oh, I suppose I have had it all my life." "No, it is a bite." "A bite? Me bitten by a dog?" Then the memory would seep in, usually, it seems, when he was hypnotized. Albert had many of the then standard symptoms of hysteria. When he was

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first interviewed, his tongue felt no pain, to the extent that a needle could be pushed through it without hurting. He had a restricted field of vision, a stan­ dard sign of hysteria in those days. He had regions of the skin which were hypersensitive and others that were completely insensitive. There is more to tell about Albert - yes, he did marry, in July 1887, and had a daughter, Marguerite-Gabrielle. They lived in Paris. His wife died of tuberculosis. The daughter was adopted by a family of market gardeners. Albert visited her regularly but continued to go on fugues. He always wanted to go north. In 1901 he was in Berlin, where he was (according to Tissie) rec­ ognized as "le voyageur de Tissie" and given assistance to get back to Tissie, who by that time had moved from Bordeaux to a smaller town in the South­ west, Pau . He stayed with the doctor for some time.30 He died on or about 28 November 1907. Tissie wrote a sad epilogue which takes us up to 7 Decem­ ber 1907. Marguerite-Gabrielle, aged fifteen and a half, is looking at a notice board that posts job opportunities. A woman comes up and offers her a job as a dressmaker. Next day, overjoyed, she puts on her best frock and sets out for work, and meets the stranger. A prostitute watching the scene says, "She'll be gone in two days.'' She is about to be abducted into the white slave trade. Document 6 is a newspaper report of these events. I end this lecture not with Albert but with more about Bordeaux. It was not only bicycle city but also double consciousness city. For it was here that the first of the new wave of French multiples began. But I need to be more precise, for a moment. Strictly multiple personality, in the sense of more than two personalities, was first noticed about a year before Albert checked into Saint-Andre Hospital. I mentioned Louis Vivet. The first descriptions of this man as a multiple, with more than two personalities, appeared in print in 1885, and the expression "multiple personality" was introduced into Eng­ lish expressly to describe Louis Vivet. There was however a long history of people with two alternating personalities - often called double conscious­ ness. The first modern instance of this phenomenon was spotted in Bor­ deaux. Her name was Felida. I like to quote Pierre Janet's lectures at Harvard in 1906: "She is a very remarkable personage who has played a rather impor­ tant part in the history of ideas . . . . But for Felida it is not certain that there would be a professorship of psychology at the College de France and that I should be here speaking to you of the mental state of hystericals.''31 The first public statement about Felida as a case of double conscious-

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ness was at a meeting of the Bordeaux Society of Medicine and Surgery, 14 January 1876, although the speaker, Eugene Azam, had first encountered her during early experiments with hypnotism some eighteen years earlier. Azam was a thoroughgoing provincial, a loyal Bordelais and Gascon, a distin­ guished bourgeois doctor. Naturally Tissie came to know Azam, even if Azam was of an altogether different social class than the self-made Tissie.32 Azam refers to Albert with great interest and favors an account in terms of double consciousness. Azam thought that Albert was more intelligent in his second state of "total som­ nambulism" than in his ordinary waking state.33 A popular book on hypno­ tism, published in 1890, has a long account of Albert, mostly abstracted from Tissie. It includes an engraving of "Dr. Tissie hypnotizing Albert in the pres­ ence of Professor Azam" (see frontispiece). An English translation of the book was published in London in 1890 and in Philadelphia in 1891, with snippets from the more sensational parts of Tissie's thesis.34 Two points must be emphasized here. Albert was never hypnotized (so far as we can tell) until some months after he entered Saint-Andre. He did not come from the culture of hypnotism in which so many hysterics and cer­ tainly multiples found themselves. He joined it. Second, Tissie to some extent did come to assimilate Albert to multiplicity, but only after he had published his medical thesis. Later he occasionally thought of Albert as hav­ ing two states, taking the terminology of "first" and "second" from Azam.35 In this way Albert came to be compared to cases of double consciousness. Tissie continued his reporting of Albert in a book titled Dreams - Freud referred to Tissie's book on nine different occasions in The Interpretation of Dreams, but only in rather general terms. Tissie came to believe that Albert's fugues often were initiated by dreams, and he developed a surprising mode of dream therapy. 36 In my opinion, Albert was substantially influenced by Tissie's therapy, but that is only opinion. I speculate about Albert in Supple­ ment 1 and examine the dangers of hypnotic influence. But in these lectures proper I do not wish to become too fixated on that one patient, paradigm though he was. Let us stand back and notice a few general points. First, as I confirm in Lecture 2, Albert did initiate an epidemic of fugues, or better, Tissie initiated an epidemic of diagnoses of fugues. Second, it has been observed in the past twenty years that about nine out of ten people suf­ fering from multiple personality, or dissociative identity disorder, are women. That has prompted the odd question, where are the male multiples? (One

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canvassed answer is, in jail.) In fin-de-siecle France it was also true that about nine out of ten multiples were women. But after Albert there was an easy answer to the question, where are the male multiples? On the road. But the fugueur was no average man on the road. He was sober, clean, respectable, a member of the working poor, by no means permanently des­ titute. An artisan, a delivery man, a clerk, a small shopkeeper, not to be con­ fused with the broad mass of tramps and vagrants whom the French popula­ tion in the 1880s came increasingly to see as a fundamental social problem. The fugueur was not from the middle classes. But he was urban or had a trade. There are almost no reports of peasant or farmer fugueurs. We have been led, very largely by the example of Michel Foucault, to ask whether madness is a mirror of sanity; in Foucault's exceptional case, to ask if madness, as conceived during the Enlightenment, is not a mirror of the Age of Reason and an essential part of that arrangement of ideas. I resist the suggestion that fugue is an essential part of anything grand. But it does reflect something: the age of tourism. Tissie saw that himself. His last comment when Albert was still alive, published in 1901, describes Albert in exactly those terms, as suffering from "pathological tourism." Make no mistake about it. This is the era of popular tourism, epitomized in the English-speaking world by the company that ran the business of tour­ ing Europe and the Levant for many years: Thomas Cook and Son. We are not talking about the grand tours of British aristocrats, county landowners, or American figures in the novels of Henry James. I refer to tourism for the masses. Cook began by hiring railway coaches to take evangelicals to tem­ perance meetings. In the second half of the nineteenth century, Cook's tourists, as they were called, were everywhere . We are talking about seven million tickets a year by the end of the century. And these tourists, though they had to pay, were as classless as the English were capable of being. 37 There were many smaller travel agents, more German than French. Tourism was expanding in the south of France, but more in the direction of Nice and Caens than Bordeaux or Biarritz. The great era of building popu­ lar tourist hotels was in full swing. You can chart the expansion of Switzer­ land as a destination simply by the hotels completed year by year- and yes, in 1882, the year of the biggest spurt in hotel construction in Switzerland, Albert found a friend who talked about Switzerland, filling Albert with an obsession to go there, which he did. Travel was not only for Cook's tourists. Travel was rebellion, poetry.

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Flaubert's orientalism, trips to Egypt, Salammbo. Baudelaire and the fi8neur, the intensely curious stroller, the traveler untroubled by time, who notices everything.38 Baudelaire penned some of his fantasies from a Borde­ lais balcony and embarked from the port of Bordeaux itself. 39 Can we see Arthur Rimbaud (1854-1891) as fugueur? Mad? Yes, or so some would say. Traveler? Par excellence. But mad traveler? He did himself often speak of fugue, meaning the word in its ordinary sense, "flight." His flights took him to places even more exotic than Albert's, even to the heart of Ethiopia, and they took place about the same time as Albert's fugues. In " Sea Breeze," an early poem by Stephane Mallarme (1842-1898), the poet exhorts himself to take flight, "Fuir! la-bas fuir! " and concludes, "Je partirai" ( I will leave).40 Jules Verne (1828-1905) captured the minds of whole generations with his trips to the center of the earth, to the moon, to the bottom of the sea, and (when Albert was thirteen years old) around the world in eighty days. This is the golden era of travel journalism, Robert Louis Stevenson with a donkey in the Cevennes or describing the new vineyards of Napa and Sonoma, whose rootstock was the savior of the ancient but infected grapes of Bor­ deaux.41 There is Mark Twain at one end of travel writing and Karl Baedeker at the other. Not that they were separate. When I wanted old Baedekers of northern France and Germany from the library at the University of Califor­ nia in Berkeley, I was told to look for them in the Mark Twain collection of the Bancroft Library; yes, Samuel Clemens had them in his pocket. To tell the truth, I have no proof that Albert did not travel with French-language Baedekers in his pocket.42 Popular tourism was one part of the ecological niche in which a new type of mental disorder, and behavior, was able to locate itself. And what bet­ ter doctor to recognize it than the great advocate of outdoor exercise, the man who, opposed to fancy gymnastic equipment and fancy athletic tracks, said that the whole of France is an exercise track, a piste du cirque? I must emphasize that tourism is only one part of the niche. In Albert's day travel had its darker side, the vagrancy scare, described in Lecture 3. I said that Albert fascinates some of us because travel has become part of the learned life and of middle-class life in general . But more than tourism hovers in the background. The "voyage" is our metaphor for self-discovery. Michel Montaigne - mayor of Bordeaux, 1581-8 5 - created the genre that we call the essay, but he also, in a small way, contributed to another genre,

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the travel diary. Montaigne was a driven traveler, seeking out health, or at least relief from the crippling pain of gallstones, but his journey to Rome via Austria and Switzerland in 158o-81 is recorded in minute detail.43 He was by no means happy to learn, wh ile in Rome, where he had been made a citizen in the course of his five months' stay, that he had been elected mayor at home and was thereby enjoined to take up residence there. Travel, for Mon­ taigne, was not exactly flight, but it was escape, a way stage between one set of Essays and the next. The idea of life as a journey was cemented for the English reader by Pil­ grim's Progress. The reader of German will invoke Goethe in Italy. Mon­ taigne, Bunyan, Goethe: these are not just accounts of travel but epigones for their respective cultures. The trip is a many-faceted symbol for our moral consciousness, sometimes positive, but also negative, as in that great amoral­ ity play, contemporary mass tourism, whose destination is io percent cathe­ drals, 20 percent eating, and 70 percent shopping. The ship of fools; the cruise ship. Thomas Mann's Death in Venice: see it as "a splendid parable on the demonic and unsettling aspects of tourism."44 What did the world of travel look like? In the introduction to Rewriting the Soul I mentioned seeing "a handsome poster of a rainy Paris street" that reminded me that we all know what the world of double consciousness looked like - it looked like the "world of the impressionists." In the spring of 1998 there was an exh ibition in Paris, gloriously represented by Juliet Wilson­ Bareau's catalogue Manet, Monet, and the Gare Saint-Lazare (New Haven: Yale Univ. Press, 1998) . Paris saw the Saint-Lazare railroad station as the cen­ ter of Europe. Located at the Place de !'Europe, it was spanned by a triumph of engineering, the Pont de !'Europe. The streets that radiate from it bear names dear to Albert: rue de Constantinople, rue de Vienne, rue de Moscou. It was here that the impressionists congregated. Gustave Caille­ botte's "Paris Street, Rainy Day" - the poster that I saw in a cafe - portrays the intersection of the rue de Lisbon and rue de Moscou. His family owned much land near the Place de !'Europe, and some of his most famous paint­ ings depict the Pont de !'Europe itself. Edouard Manet lived at 4 rue de Saint-Petersburg from 1872. His stunning "The Railway" (often called "the Gare Saint-Lazare") is painted from rue de Rome. After 1878 Claude Monet (whom Caillebotte supported) had his home on the rue d'Edimbourg, just off the rue de Rome. Monet painted twelve impressionist classics of trains

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inside the Gare Saint-Lazare. Emile Zola declared : "That is where painting is today. . . . Our artists have to find the poetry in train-stations" (Wilson-Bar­ reau, p. 105) . The impressionist exhibition of 1877 was, in effect, about rail­ ways, the station, the Europe bridge, and the Europe quarter generally. Hence we know exactly what the world of travel looked like at the time that Albert began his astounding trips. And Caillebotte's painting of Monet on a dirt road, used as the cover of this book, could be a portrait of Albert's alter ego. Albert's obsessive and uncontrollable journeys were systematically point­ less, less a voyage of self-discovery than an attempt to eliminate self. In Lec­ ture 2 I describe how they inaugurated an epidemic of mad travel and use that as a peg on which to hang issues about the reality of mental illness. You can read Albert in so many other ways precisely because travel signifies so much in the whole of Western civilization, from the Odyssey to outer space, with much else, including John Bunyan's soul, packed in between. Yet for all these important excursions, let us not lose sight of our main topic, the reality of mental illness. Tissie himself, furious at the way in which military tribunals had treated Albert, without taking notice of medical advice, had this to say: "When we consider the damaged life led by this poor lad and the number of times in which he had business with the law, which led regularly to prison, we cannot help protesting against the arrogant and criminal incompetence of the magistrate who exclaimed: 'What need have we of the help of the physician in order to appreciate the disorders of the mind? If madness is evident, everyone can recognize it by its extravagances or its fits of rage; if there is a doubt, a doubt exists equally for the doctor!"'45 "That," wrote Tissie at the end of his study, "is the moral that we would like to draw from our thesis." He was rejecting a very old text indeed, a foren­ sic treatise of 1830.46 We now take for granted that courts of law do need expert medical testimony, although in the back of our minds there still lurks, I suspect, a certain longing for that simple jurisprudential doctrine of 1830 deep in our hearts, we know what madness is! But we have moved on. Today the issue is not expert witnesses but the relationship between what they tell us and the way in which their patients become ill. We have not got clear in our minds, yet, the interaction between expert knowledge and the behavior of troubled people. That is the underlying theme that we must pursue .

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ow can a form of mental illness emerge, take hold, become an obsession in some place and time, and then, perhaps, fade away? I am leading you through an example. First, a single patient. In this lecture, a plethora. How could Albert and his doctors have started a verita­ ble cascade of fugueurs, or at any rate of fugue diagnoses? This is not just a question about fugue but an exemplar for thinking about a whole group of mental illnesses, past and present. I need to document the outbreak, but that is the stuff of notes. There was a pretty pattern of national spheres of influence. In 1887 Bordeaux. In 1888 Paris. Soon, many regions of France and northern Italy. Then, a decade later, in 1898, a German physician, observing the French work, exclaims, where are the German fugues? Where is the German research? His coun­ trymen rally round. Within five years the number of published German stud­ ies of fugue swells, and there is even a survey article so that other German doctors can catch up. That is only the beginning. Russia follows suit. 1 The contours of German fugue are different from those in France. The niche for fugue not only was found later in Germany than in France but also made use of a slightly_ different medical, social, and military context that I describe in Supplement 3. More interesting to us is that fugue did not "take" 31

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in America . We have something like an experiment, not a controlled one, to be sure, but a living example of how fugue became a common diagnosis in some milieus and was rejected by others. First I need to describe the dynamics of the outbreak of fugue in the heartland, in France itself. I have talked about 1887. In this lecture it is 1888---