Friday, April 10, 2009

Hysterical Men: The Hidden History of Male Nervous Illness by Mark S. Micale

Sherwin B. Nuland reviews the recent book by Mark S. Micale, Hysterical Men: The Hidden History of Male Nervous Illness, over at Powell's Bookstore, originally posted at The New Republic.
Hysterical Men: The Hidden History of Male Nervous Illness
by Mark S. Micale

Macho Misery

A review by Sherwin B. Nuland

As far back as has been recorded of the history of human societies, men have equated life with movement. If our ancestors of antiquity could feel stirrings inside their bodies, it must mean that large, living structures were at the very least shifting their positions, and perhaps even migrating from place to place within the mysterious recesses of the internal cavities that encompassed them, whether the abdomen or the chest. Like other peoples of their time, for example, the Egyptians believed that the inner organs were so many distinctive and individual creatures, with whims and moods of their own that determined their peregrinations from neck to pelvis.

Of all the named structures within the abdomen and the chest, those associated with reproduction retained the mysteries of their willful behavior long after others had been solved to the satisfaction of physicians and philosophers. When, in his Timaeus, Hippocrates's contemporary Plato called the uterus "an animal within an animal," he meant it to be taken literally. He was echoing a common belief of his time and earlier when he stated that under proper conditions the womb -- or hystera, as it was called in Greek -- "becomes seriously angry and moves all over the body." Chief among those proper conditions was any frustration of its desire to bear children.

Though the Hippocratic physicians themselves, in their general disavowal of the mystical, rejected any idea of all but relatively small degrees of uterine movement (and even that was thought to occur only within the pelvis), most of their medical contemporaries continued for centuries to insist that the female gestational organ had the capacity to leap all over the place, whether through the diaphragm and up into the neck or sideways, downwards, and anywhere else within the body cavities where it might find expression for its moods. In Book II of On the Causes and Symptoms of Acute Disease, Aretaeus the Cappadocian, one of the most prominent physicians of the second century C.E., wrote a chapter entitled "On Hysterical Suffocation," in which he described the various symptoms that he attributed to the womb's wanderings, as well as his certainty that it is attracted toward what smells fragrant and flees from what is fetid. Not only odors and barrenness, but also a demanding sexual dissatisfaction, had been implied since Egyptian times as the etiological basis for uterine rovings.

In Aretaeus's description are to be found many of the clinical manifestations associated with the emotional state which in later centuries would become known as hysteria, for the organ with which they were associated. Aretaeus describes what he calls the womb's displacement resulting in violent pressure on other organs, which may result in choking, loss of breath, vertigo, fainting, unconsciousness, headache, loss of function of the extremities, and irregularities of the heartbeat. Even authorities such as the Hippocratics and the great Galen, the giant of medicine in the second century C.E. whose powerful influence would persist for a millennium and a half -- and who denied the notion of significant uterine wandering -- believed that hysterical symptoms are related to unrequited sexual passion, which was said to deprive the uterus of necessary health-giving moisture. Galen is known to prescribe sexual intercourse for the malady, or manual stimulation of the clitoris or uterine cervix. One way or another, sexually or maternally, the frustrated womb was destined to remain the imputed source of hysteria for many centuries, well into the period when experimental and clinical science had become the basis of the healer's art. And quite obviously, since hysteria originated in the hystera, it could not occur in men.

The rising influence of Christianity meant that the naturalistic views of the ancients were displaced by the clergy's supernatural explanations for disease, and the notion that human suffering was the consequence of evil acts or inclinations. Since hysteria exhibited such erratic and otherwise unexplainable symptoms, it was interpreted by many, including the influential Augustine, as evidence of possession by the devil. Ecclesiastical trials were held, prayers and incantations were offered, and many a woman and girl was burned as a witch. All through this period of perhaps a millennium or more, hysteria remained a disease exclusively, archetypically, of females.

The early modern centuries brought a return to -- a renaissance of -- the search for natural explanations of the phenomena of nature, and particularly of the human body. The writings and the recommendations of the earliest medical scientists and the new breed of clinicians between the mid-fifteenth and early seventeenth centuries were based on the supposition that sufficient study and experimentation would elucidate not only the origins of disease, but its treatment as well. Still, even the most eminent of the new scientists continued to believe that the symptoms of hysteria were related to some dissatisfaction and consequent displacement of the womb and perhaps other of the female generative organs. Thus, the disease known commonly as the hysterical passions was likely, in medical writings, to be called uteri adscensus, suffocatio uterina, strangulatio vulvae, or some similar designation.

The Scientific Revolution, that remarkable transformation of European thought that occurred between approximately 1550 and 1700, brought with it an ascendancy of the experimental method and the refusal to believe any explanation of natural phenomena that could not be proven to the satisfaction of the empirical observer. When large numbers of autopsies were performed on women who had died of what was thought to be hysteria, no evidence of uterine abnormality could be identified by objective eyes. Toward the latter part of the seventeenth century, attention was accordingly turned to the brain and nervous system, with the result that two of the leading English physicians of the time, Thomas Willis and Thomas Sydenham, put forth what might be called a "neuropsychological" theory of many diseases, and especially of the so-called "hysteria," which neither of them believed to be in any way connected with the female reproductive organs.

If Willis and Sydenham were correct, the symptoms of hysteria could be found in men -- and these physicians showed that they did indeed occur in certain of their male patients. At this point, enter, or re-enter, hypochondriasis, a disease found usually in men and much less commonly in women, which had been recognized from the time of the Greeks, and characterized by discomfort beneath the lowest ribs (perhaps radiating in all directions from the spleen), spreading out into a cluster of unexplainable symptoms very similar to those of hysteria. These provocative suggestions led to a wide variety of theories that were united by the fact that they all referred to these phenomena as "nervous distempers," a term we might replace today by "psychosomatic" or "psychoneurotic" illness.

Nervous distemper became a fashionable diagnosis during the Georgian period of the eighteenth and early nineteenth centuries, most particularly as evidence that the patient so afflicted, whether male or female, was of a "feeling" or "sentimental" disposition. Since such a high degree of sensitivity was required to contract it (and it had lost its uterine connotations of effeminacy), the symptoms were soon socially restricted to the upper classes. All manner of authors, poets, philosophers, scientists, composers, and other varieties of intellectual were said to have it, and it was with a certain sense of pride that the well-bred Englishman took to calling it "The English Malady." Unwilling to leave its social and cultural significance to the British alone, many on the Continent claimed it as part of the human condition. Despite the discomforts of its symptomatology, it was unmistakable evidence of refinement. And its very acknowledgement made it permissible for men to admit, finally after more than two millennia, to certain emotional states that had been thought to be the exclusive burden of women. As the medical historian Mark Micale makes clear in his illuminating description of these events and their consequences, "It is not today's psychiatric writing about post-traumatic stress disorders, nor the medical commentary on 'shell-shock' during the First World War, but the early modern discourse on the nervous distempers that represents the first instance of the medicalization of male emotional suffering in the European West."

That sentence articulates one of the underlying messages of Micale's fascinating and important book. For the story of nervous maladies has been, from approximately the end of the Georgian period until relatively recently, a story in which male physicians have returned to their earlier habit of bringing forth theories of female emotionality and mental frailty based on their close -- and obviously biased -- observation of women, while failing to acknowledge, or perhaps even to observe, that men of all social classes could be shown to suffer from the same ailments. Not from lack of evidence or cases to study did this situation exist, but for a complex of reasons personal and general, ranging from the anxieties of the individual male observers all the way to the growth and perpetuation of a reliable economic and civil order in nineteenth-century society -- the political and cultural imperative of a patriarchal structure in which the image of stability and dependability of the rational, clear-thinking male was assured. "Sustaining patriarchy, however," Micale makes clear, "required both idealizing the virtues and denying the vulnerabilities of hegemonic bourgeois masculinity." As a result, the homogeneously male medical community leaned toward restricting their diagnoses of nervous disabilities almost exclusively to female patients, thus contributing to a model of masculine human nature which, although fragile and ultimately shown to be untenable, operated successfully over a span of more than two centuries.

Seeking writings in which symptoms of male hysteria are described in the long period prior to Freud -- except, as noted above, during the reign of "The English Malady" -- one would have to look for the most part to non-medical sources, because there are figures from the worlds of literature and even philosophy who did not shrink from describing such states, not infrequently in themselves. Whether these sorts of writings are more common or less so in any era, Micale points out, would seem to depend on the degree of gender polarization and general liberalization of the era. Times perceived as periods of stability and personal security were times, he tells us, in which introspective authors were more likely to write, sometimes confessionally, of symptoms recognizable as those of male neurosis. Another factor appears to have been whether the writer conceived of hysteria as a neurologic and therefore physically based disorder, or as one that was psychological and therefore based in emotions. Micale provides an interesting, original, and I believe quite accurate, list of examples of the latter: Burton, Shakespeare, Mandeville, Hume, Cheyne (an eighteenth-century Scottish physician, and the author of a widely read book called The English Malady), Johnson, Wordsworth, Mill, Flaubert, and Freud. Of the former, he lists Sydenham, Georget (a nineteenth-century French psychiatrist) and the great Charcot.

In one of the strikingly insightful passages that are characteristic of Micale's perceptive way of looking at the influence of the surrounding culture on European medical thought, he points out that "for most thinkers who were open at all to this line of investigation [the psychological/emotional], literature and introspection were doubtless natural, even inevitable, allies in the systematized study of subjectivity, whereas the strict and exclusionary methodology of positivist science seemed insufficient to the task." The organized research methodology of the laboratory and the university clinic, presented in language that Micale refers to as "the opaque and impenetrable surface of medicine's official rhetoric of science," served to screen the mind of many a thinker from any but a gender-specific interpretation of what was being observed.

The period between the waning years of the Enlightenment and the beginnings of psychoanalysis -- roughly speaking, the nineteenth century -- was a period of burgeoning activity among an increasingly large group of men dedicated to the intellectual discipline of what Micale correctly calls "positivist science," a way of thinking that demands the intellectual and personal distancing of the investigator from the phenomena or persons being investigated. If one studies this era carefully, as he has done to our benefit, it can be observed that the injection of the self into cogitations about human behavior was vigorously rejected, to the point where any such inner envisionings were considered not only unscientific but even unmasculine, a threat to the self that must be avoided at all costs. And this introduces another consideration: Micale argues, quite originally to my knowledge, that "the specter of male physicians gazing with passionate intensity on other adult men in intimate emotional distress suggested an unacceptable homoerotic intimacy."

The foregoing factors, bolstering one another, brought about a long stretch of time when the likelihood of identifying the reality of the real hysteria, the gender-free hysteria, became vanishingly small. It was not until psychodynamic psychiatry appeared, heralded by the studies of Freud toward the end of the century, that the terra incognita of the human psyche was accepted by scientifically-minded physicians as an independent field of study, one that must be explored without pre-judgment regardless of where the investigator might be taken by the clues that appeared, especially if from their own internal thoughts. Despite their splintering into sects, the new groups of observers of the mind's inner workings probed in usefully subjective ways into problems that they recognized as arising in the depths of the unconscious mind.

Like a wind of freshness not to be denied, the new thinking, much more free of a gendered notion of illness than its predecessors, spread to successive generations of mental health workers after Freud, with the result that notions such as the exclusively feminine nature of hysteria began to be eroded. But after some three millennia in which it dominated, the concept of the disgruntled hystera has proven to be difficult to dislodge. The Diagnostic and Statistical Manual of the American Psychiatric Association for 1979, known as DSM-III, still listed "hysterical neurosis" as an accepted entity, and it was not until 1994 that it was replaced in DSM-IV by the term "conversion reactions".

Though the scientists and physicians of the nineteenth century clung adamantly to notions of female-gendered hysteria, the work of at least one of them contained powerful elements that would presage the beginnings of change. Jean-Martin Charcot, appointed in 1862 to be chief of medical service at the huge Parisian hospital complex called the Salpetriere, became increasingly interested in neurological diseases. It was in the 1870s that he turned his prodigious attention to the problem of hysteria, and began to publish the clinical descriptions of dozens of such patients, many of whom were men. His writings refuted uterine theories of hysteria that were enjoying a resurgence of popularity in Germany, Great Britain, and the United States. Though it was his opinion that twenty female victims of the disorder existed for every male, he insisted not only that the uterus had nothing to do with the case, but also that male hysteria could occur in any social class, including the most impoverished. More, he stated boldly that there was nothing particularly effeminate about his male patients, a notion that others had put forth to link its existence to lack of proper masculinity or to excessive refinement.

It was Charcot's belief that hysteria's cause was relatively simple: it was due to an underlying hereditary predisposition upon which an acute triggering episode is suddenly imposed. When he was unable to identify the hereditary organic lesion or chemical imbalance in any of the sixty-one males whose histories and findings he published, he explained its absence by postulating the existence of an as-yet-undetectable diffuse physiological abnormality of the nervous system. He was certain that the nature of the abnormality would eventually be discovered with advances in science. In other words, Charcot felt certain that hysteria was an organic disease and no respecter of gender differences.

Charcot's suppositions did not sit well with many European and American neurologists. They reasoned that since the actual organic basis of hysteria had not been discovered, it might mean that the origin of the illness would be found in the psyche, and therefore the psyche of the male and of the female are less different one from the other than had always been supposed. Such a notion, Micale suggests, made many physicians distinctly uncomfortable and therefore ambivalent about the very conclusions that they were drawing from Charcot's rigorous work. One response to this was to make little or no mention of male hysteria in the textbooks of the time. Another was to deny the statistic of one in twenty, and ratchet it up to one in a hundred or higher. Some authorities ignored hysteria completely or combined it with other diseases when making the diagnosis in men, so that new entities such as hysteroepilepsy, hystero-neuropathy, and traumatic hystero-neurasthenia began to appear, always far more frequently among male than female patients.

No matter their approach, the typical French physician who accepted the notion of male hysteria continued to think that its victims were in some way sexually abnormal: "Thus, despite Charcot's innovative work, the male victim of hysteria in late-nineteenth century French medical imagination was still frequently envisioned as an effeminate heterosexual, an overt homosexual, or a physical or emotional hermaphrodite." If not different sexually, male hysterics were said to be different in other ways, such as race or nationality, among whom African, African-American, south Asian, Arab, or Eastern European Jewish men predominated. Outside of France, other methods of denial appeared, such as the suggestion that male hysteria was restricted to Frenchmen. The medical literature of the time is full of evasions and denials and contradictions of the truths that Charcot had quite obviously demonstrated.

These trends were reflected in the artistic contributions of the period, exemplified most perfectly by the literature of the so-called French decadent school as well as by the large number of sexually ambiguous characters that appeared in its paintings. The parallel in Britain was the aesthetic movement and a tradition of literary homosexuality. Another factor was the noteworthy British phenomenon that manifested itself as the movement that Micale refers to as "the literature of generational revolt," in which young men reject the Victorian authority of powerful patriarchal figures. Throughout Europe and America, writers and artists were attacking the rigid images of high Victorian respectability, but the physicians remained reluctant to join them. In the midst of all of this, a twenty-nine-year-old graduate of the University of Vienna medical school with advanced training in clinical medicine, brain anatomy, and neurological research, arrived in Paris, in 1885. Sigmund Freud was dazzled by Charcot, and deeply impressed by his work on hysteria. He soon abandoned any thoughts of continuing his microscopical and laboratory work, and began to study his idolized teacher's notions of the importance of traumatic experiences. When he returned to Vienna in April 1886 to open his private office, nervous disorders, and particularly cases of hysteria in both men and women, comprised most of his practice. By October of that year, he appeared before a meeting of the Vienna Society of Physicians to lecture on a case of male hysteria he had seen in Paris, and returned five weeks later to discuss a case of the disorder in a patient of his own, and implications of its characteristics that can only be described as psychoanalytic. As Micale notes, "Psychoanalysis originated as a theory and therapy of hysteria, the paradigmatic malady of fin-de-siecle Europe; but Freud's initial encounter with the neurosis began with his study of hysteria in men."

As time passed, Freud turned increasingly away from Charcot's organic explanation and looked into the psychic pre-history of the disease and the unconscious and sexual lives of his patients, both male and female. When in 1895 he published, with Josef Breuer, Studies on Hysteria, the volume that Micale calls "the first distinctly psychoanalytic book," he illustrated his emerging theories by describing five patients, all women. Micale enumerates several possible reasons for the absence of male examples (though Freud had treated many), of which Breuer's reluctance to play the intellectual revolutionary is the most convincing.

After Freud broke with Breuer and took up a new and productive relationship with Wilhelm Fliess, he relied more and more on the combination of personal self-examination and the clinical observation of his patients. His self-analysis became a crucial element in his investigative methodology, along with his case studies and his voluminous reading. Considerable academic scholarship has been devoted to the Freud-Fliess correspondence since it was published in the 1980s, all erroneously stating that Freud's hysteria patients of the 1890s were entirely female. There were in fact many male analysands, and they were just as important to the evolution of his theories -- about hysteria and everything else -- as their feminine counterparts. The fact is that the notion of male hysteria has remained difficult for male physicians to accept, even in relatively recent times. Among other reasons for this state of affairs, claims Micale, the "turning of the male gaze inward" at itself is too threatening, too fraught with the danger of discovering elements of femininity in the masculine psyche, too much liable to result in an unacceptable homoerotic perception. "Fear, vanity and the drive for power are the underlying sentiments operating in this story."

With the progress of psychoanalytic psychology introduced by Freud, the psychodynamics underlining the denial have been revealed, Micale tells us, to be that the male "psychological imperative to free oneself from infant maternal identification ... requires a continual censuring of the eternal 'feminine within.'" Culture often operates against science. For hundreds if not thousands of years, these traditions of gender stereotypes and sexual anxieties have hindered opportunities for insight into the existence and the nature of male hysteria.

The long tale of hysteria makes a fascinating, if often convoluted, story. It would have been all too easy for a writer without Mark Micale's skills to have lost his readers within the multiplicity of theories, debates, terminologies, and misapprehensions of various epochs, but he has somehow managed to follow the tortuous narrative line through a tangle of disconnected confusions that are all but incomprehensible to a twenty-first-century mind. Certainly, it was often incomprehensible to physicians, intellectuals, and other reasonably well-educated people who lived through hysteria's various incarnations and explanations. But Micale has done more than tell a good story. He has made numerous perceptive interpretations along the way, scouring the state of concomitant literature and art in order to seek the ambient clues that come together to form the supporting structure for much of his theoretical speculation.

What Micale has accomplished is a tour de force of medical, cultural, and psychological detective work. In his hands, the three-thousand-year refusal of the medical world to acknowledge the existence of hysteria in any but females is proven to have a perfectly understandable psychoanalytic basis, but it has taken a scholar of wide-ranging intellectual background and enormous perspicacity to build, era by era, to its discovery and the construction of his impressively supported thesis. He has provided a model for other scholars to follow, not least in demonstrating by example that a historian of medicine must be also a historian of culture.

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