Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis (23 page)

Nonetheless, the majority of patients diagnosed with such hysterical disorders—psychogenic nonepileptic seizures included—have always been female. Hence the treatments for hysterical symptoms, developed almost entirely by male physicians, focused on the female reproductive organs and genitalia.

From the ancient era of Hippocrates to Galen and then continuing well into the twentieth century, physicians routinely employed a treatment for hysteria that is highly ironic in retrospect: Doctors would massage the genitals of their female patients until they responded with a “hysterical paroxysm,” after which point their symptoms would subside. The “paroxysmal state” was, of course, an orgasm, and the written descriptions that persist recounting these events render it nearly impossible to believe that the majority of clinicians over the centuries did not recognize it as such, and yet they apparently did not. Galen, for example, in the second century
A.D.,
described the resolution of a patient’s symptoms after genital massage that resulted in contractions and the expulsion of fluid from the vaginal orifice. Seventeen centuries later, the American gynecologist William Goodell believed that vulval massage should be used to “relieve pelvic congestion” in hysteric patients. Rachel Maines, in her always compelling and often hilarious book
The Technology of Orgasm,
deadpans of Goodell, “His patients reported a desire to sleep after treatment.”

Maines describes how physicians, in an attempt to reduce the time spent on genital massage in their practices, led the quest to develop and market the vibrator. Medical practitioners remained utterly oblivious to the sexual nature of their treatments, a fact that Maines attributes to the “androcentric” view of the times, in which women were thought to be sexually aroused and fulfilled only when penetrated.

This misconception gave rise not only to the blasé and clinical view of female genital massage but also to a spate of laughable fears that surrounded the invention of the speculum. As the nineteenth century drew to a close, “any object or device that traveled the path of the totemic penis into the vagina was . . . suspected of having an orgasmically stimulating effect,” Maines writes. “The widespread adoption of the speculum as a medical instrument was far more controversial than that of the vibrator a few years later. Elaborate tales were related of women and girls lusting after medical examination and climaxing on the examining table the minute the speculum was introduced.”

Though speculum-induced climaxes are hard to imagine, Maines makes clear that climaxes were indeed happening through the other treatments. In 1653, Pieter van Foreest opined in his
Observationum et Curationum Medicinalium ac Chirurgicarum, Opera Omnia,
“When these symptoms indicate, we think it necessary to ask a midwife to assist, so that she can massage the genitalia with one finger inside, using oil of lilies, musk root, crocus, or [something] similar. And in this way the afflicted woman can be aroused to the paroxysm.”

Delegation of the task to midwives was a means of saving physicians time, effort, and frustration deriving from the seemingly complex task of stimulating women’s genitals. Maines writes, “The job required skill and attention; Nathaniel Highmore noted in 1660 that it was difficult to learn vulvular massage. He said that the technique ‘is not unlike that game of boys in which they try to rub their stomachs with one hand and pat their heads with the other.’”

Several less appealing treatments were devised to coax the wayward uterus back into place. Women with hysterical symptoms were made to sit above burners that wafted supposed womb-attracting fumes up into their nether regions. All manner of plants and oils were inserted into women’s bodies to treat hysterical diagnoses ranging from insomnia and fainting to nervousness and convulsions.

It comes as no surprise, then, that massage-based treatments proved to be the more popular approach. As demand for massage grew, so did the amount of office time a physician could spend bringing his female clientele to their hysterical paroxysms. Rachel Maines writes that “there is no evidence that male physicians enjoyed providing pelvic massage treatments. On the contrary, this male elite sought every opportunity to substitute other devices for their fingers, such as the attentions of a husband, the hands of a midwife, or the business end of some tireless and impersonal mechanism.”

That mechanism was the vibrator, conceived of and developed by a nineteenth-century British physician as a “capital-labor substitution option,” which “reduced the time it took physicians to produce results from up to an hour to about ten minutes. . . . Mechanizing this task [of genital massage] significantly increased the number of patients a doctor could treat in a working day.” Samuel Spencer Wallian agreed in 1906, stating that massaging a patient by hand “consumes a painstaking hour to accomplish much less profound results than are easily effected by the [vibrator] in a short five or ten minutes.”

Soon vibration treatments were not only available in the home but advertised widely in various upstanding women’s publications. “In the first two decades of [the twentieth] century,” Maines writes, “the vibrator began to be marketed as a home appliance through advertising in such periodicals as
Needlecraft, Home Needlework Journal, Modern Women, Hearst’s, McClure’s, Woman’s Home Companion
, and
Modern Priscilla.
The device was marketed mainly to women as a health and relaxation aid, in ambiguous phrases such as ‘all the pleasures of youth . . . will throb within you.’ An especially versatile vibrator line was illustrated in the Sears, Roebuck and Company
Electrical Goods
catalog for 1918. Here an advertisement headed ‘Aids That Every Woman Appreciates’ shows a vibrator attachment for a home motor that also drove attachments for churning, mixing, beating, grinding, buffing, and operating a fan.”

•   •   •

T
hough there is a decidedly comical element to treating somatoform disorders with vibrators and orgasms, far more sinister and less benign treatments were also employed. Had Phyllis’s seizures occurred in the nineteenth century, she might as easily have been treated drastically, ineffectively, and possibly catastrophically with surgery. Though physicians largely agreed that the locus of female hysteria was the womb, the approaches as to how best to treat the trouble with the genitals diverged sharply. In
From Paralysis to Fatigue,
Edward Shorter writes that “it was a short step from seeing genital lesions as the cause of mental disease to repairing them as a cure for it. And in one of the most audacious leaps in the history of nineteenth-century medicine, that is exactly the step that was taken. Gynecologists began operating on their patients to cure hysteria and insanity in an era that knew no antibiotic drugs against infection and that took only cursory precautions with surgical cleanliness.” Indeed, half of all surgical patients in the 1830s and 1840s died either during surgery or postoperatively, from surgical complications.

Yet swiftly and without substantial challenge, the field of psychogynecology was born. A procedural approach to treatment, which began with local “remedies,” such as carbolic-acid washes of the vulva, vagina, and cervix, evolved and gave way to major operations in which women’s abdominal cavities were opened and their reproductive organs were surgically altered or removed. In the name of treating hysteria, hysterectomies were performed, uteruses were sewn to the abdominal wall, clitorises were cut out, and scores and scores of ovaries were removed from women of all ages. And these measures were heralded as great advancements in the field of medicine. In the late nineteenth century, Alfred Hegar, a professor of gynecology at the University of Freiburg, touted gynecology as “the bridge between general medicine and neuropathology.” In this spirit, Hegar removed the ovaries of a twenty-seven-year-old who had complained of severe menstrual pain. She developed a postoperative infection and died shortly afterward from peritonitis. Nonetheless—and despite documented evidence of women’s psychiatric illnesses persisting or worsening after surgery—physicians’ enthusiasm for removing women’s ovaries trundled on. It spread across Europe and across the Atlantic to America, where asylums hired staff gynecologists to perform pelvic surgery on their psychiatric inpatients.

Edward Shorter points out that male hysterics—of which there were many—were not routinely treated with castrations. Their physicians apparently—and no doubt accurately—presumed they would not like it: “Archibald Church, a neurologist at Northwestern University . . . said in a discussion at a joint meeting of obstetricians and other specialists in 1904: ‘Men do not accept mutilating operations upon the genital tract with the equanimity which is presented by the gentler sex, who peaceably accept unsexing operations without much question as to their effect, provided they can be relieved of some trivial or temporary ailment.’”

•   •   •

A
fter I left Phyllis’s floor, having written a note for the morning doctors and made sure she got her ginger ale, I headed back to my post in the psych ER. The overnight nurse, Ellen, was there, talking with José, a mental-health worker, about the latest change in the Red Sox pitching rotation.

“So what was the big emergency?” Ellen asked.

“Pseudoemergency,” I responded.

“Oh, you’re kidding!” she groaned. Then she hit José lightly on the arm. “Hey, remember that doozy of a pseudoseizure we had in here a couple of years ago? That woman we seriously thought was gonna die? It was wicked hot. Like July or something. Remember? At first we thought she was on drugs, then we thought it was the heat—”

“Oh, my God!” José interrupted. “I
totally
remember. That woman was foaming at the mouth, and it did
not
stop, just kept going and going.”

“There were all these other patients around.” Ellen turned to me, filling me in on the story. “And they started freaking out. Going, ‘What did you give her? What kind of place is this?’ Like we had poisoned her or something.”

Then José jumped back in. “And remember that guy . . . my God, it had to be four, five years ago, the one who kicked a hole in the door with his heel?
That
time I was sure it wasn’t a pseudoseizure . . .”

They went on, swapping stories. Psychogenic nonepileptic seizures have long been viewed in this way—as a kind of spectacle—dating back at least as far as the nineteenth century and Jean-Martin Charcot.

Charcot, one of the most charismatic figures in medical history, fueled the nineteenth century’s focus on hysteria. As the chief of neurology at the Salpêtrière Hospital in Paris, he became internationally known and revered as the master of diagnosis and treatment of hysteria. Letters sent from across the world needed only to be addressed to “Charcot . . . Doctor in Europe,” and they would reach him.

Charcot was uniquely situated to conduct research on women who were mentally ill. In 1880 he wrote, “Among the five thousand female inhabitants of this great institution called the hospice of the Salpêtrière were a large number admitted for life as incurable, patients of every age with every kind of chronic disease, in particular disorders having the nervous system as their seat.” He made no bones about classifying his patients as objects for his scientific perusal. “We found ourselves,” he continued, “. . . in possession of a kind of living pathology museum whose holdings were virtually inexhaustible.”

In the midst of his “museum” full of hysterics, Charcot developed an elaborate study of what he called “attacks of hystero-epilepsy,” a more sensational and arguably less authentic variation on today’s psychogenic nonepileptic seizures. His patients would convulse, faint, flit in and out of consciousness, cry out with piercing wails, flail about their beds, exhibit pelvic thrusting, become immobile in the position of prayer or crucifixion, or strike Charcot’s emblematic pose of hysteria: the
arc-de-cercle,
or
arc-en-ciel,
in which only their heels and the backs of their heads would be touching the ground.

Charcot’s few critics and detractors cited “hystero-epilepsy” as an illness that had been invented, not discovered, at the Salpêtrière. They accused Charcot of developing a culture of suggestion in which women were admitted with vague complaints and then continually exposed to other patients’ behavior and symptoms. Eventually the women exhibited symptoms that conformed to Charcot’s prized diagnosis and were rewarded with his interest and the encouragement of the staff. Ostensibly to silence his critics, Charcot began holding lectures and demonstrations to which the public was invited. He would let the people see this disorder, he said, and decide for themselves whether they believed in his ability to identify, induce, and treat hysteria.

Charcot’s “spectacles” became a notable destination for education, but mostly for entertainment. Axel Munthe, a psychiatrist and student of Charcot’s who eventually became his critic, described the scene in detail, and not without derision: “These stage performances of the Salpêtrière before the public of . . . Paris were nothing but an absurd farce, a hopeless muddle of truth and cheating. Many of [the patients] were mere frauds, knowing quite well what they were expected to do, delighted to perform their various tricks in public, cheating both doctors and audience with the amazing cunning of the
hystériques.
They were always eager to
‘piquer une attaque’
of Charcot’s classic
grande hystérie, arc-en-ciel
and all, or to exhibit his famous . . . stages of hypnotism, . . . all invented by the Master and hardly ever observed outside the Salpêtrière. Some of them smelt with delight a bottle of ammonia when told it was rose water, others would eat a piece of charcoal when presented to them as chocolate. Another would crawl on all fours on the floor, barking furiously when told she was a dog, flap her arms as if trying to fly when turned into a pigeon, lift her skirts with a shriek of terror when a glove was thrown at her feet with a suggestion [that it was] a snake.”

Despite Charcot’s view of himself as an explorer of new psychiatric and neurological territory, his stance on the etiology of his patients’ symptoms conformed to the prevailing theories of the day. Like his colleagues in Europe and beyond, he believed that the problematic locus of hysteria was the ovary. When a patient at the Salpêtrière who had been plagued by hysterical symptoms died, Charcot would largely ignore the brain in the autopsy, instead examining the ovarian tissue under a microscope for pathologic clues. His proposed remedies also targeted the ovaries. Charcot believed (and repeatedly demonstrated) that a hysterical attack could be made to cease (or sometimes begin) simply by the exertion of pressure on the ovaries. To that end, one of his intems developed a fit-preventing “ovarian compressor belt” that supposedly applied constant pressure to these organs.