You wake up one morning, the whole world is grey, you have had enough of your cold, colourless life. You want to drop everything, escape, far away, where life is real. Who has not had this dream from time to time? Nothing could be more normal. The desire to escape, to travel, is deeply rooted in everyone, from the young runaway to the tourist, from the beatnik to the Sunday hiker. But suppose now that this desire to flee becomes an obsession, a truly irresistible compulsion. Suppose further that it all happens in a state of absence and you cannot remember any of it: you arrive somewhere, dazed, without the slightest idea of what happened in the interval. Obviously, you have become a pathological runaway, a mad traveller, fit for the asylum and for therapy.
So how do you get from normal escapist desire to mad travelling? What is the difference between these two, almost identical impulses? How did you become mentally ill? Besides, are you really ill? Ian Hacking has written a wonderful philosophical fable about these and several other equally fascinating questions. Its moral is simple, if somewhat untimely: what we call ‘mental illness’ is not a permanent, intangible reality. For it to develop, it needs a hospitable environment, what Hacking compares to an ecological niche. Without a facilitating environment, mental illness languishes, wastes away, disappears, or emigrates somewhere more propitious. You who dream of dropping everything, for example, there is almost no chance of your becoming a pathological fugueur. Our modern psychiatric bibles may still make room for the diagnosis of ‘dissociative fugue’, but there is no longer, in late 20th-century Europe, any ground on which that illness could truly thrive. A century ago it was different. Hacking is more precise (or peremptory): fugue, he claims, became an illness in 1887 with the publication of Philippe Tissié’s Les Aliénés Voyageurs, and it began to wane after the 1909 congress of alienists and neurologists in Nantes.
Hacking even gives us the name of the first pathological fugueur: Jean-Albert Dadas, an employee in a gas equipment company in the Bordeaux region. Tissié spotted him in 1886 at the Hôpital Saint-André in Bordeaux:
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 kilometres a day on foot, until in the end he would be arrested for vagrancy and thrown in prison.
This strange compulsion had seized him for the first time when he was 12. He had suddenly disappeared from the gas factory where he was an apprentice, and when his brother found him in a nearby town, he had seemed to awaken from a dream, astonished to find himself there. As a rule, his attacks were preceded by migraines, insomnia and sessions of intense masturbation. Dadas would then take to the road and walk, walk, till he found himself in some place that he had heard about: Paris, Marseille, Algiers, Frankfurt, Vienna, Moscow, Constantinople (Hacking provides us with a map of his impressive peregrinations across Europe). Dadas never remembered much, but Tissié quickly realised – this was 1886, the golden age of hypnotism – that you only needed to put him under hypnosis to have him recollect the sometimes picaresque details of his travels. Tissié also had photographs taken of Dadas, in which we see him in his different states: normal (perky, smiling at us); at the end of an attack (groggy, stupid); under hypnosis (asleep, eyes closed).
Tissié diagnosed a form of hysteria. Dadas, he noted, had all the ‘stigmata’ of hysteria listed by Charcot: anaesthesias, hyperaesthesias, narrowing of the field of vision and the like. Charcot himself was of a different opinion. The following year, in the course of his Tuesday lectures at the Salpêitrière, he presented a second fugueur and advanced a diagnosis of ‘ambulatory automatism’, a latent form of epilepsy. With the authority of the Master, the fugue was launched. In the following months and years the literature presents an avalanche of similar cases, some described as ‘ambulatory automatism’ (or ‘delirium’), others as ‘hysterical (or psychasthenic) fugues’. New names are invented for the phenomenon: dromomanie, poriomania, determinismo ambulatorio (in Italy), Wandertrieb (in Germany, some ten years later). In 1893, Henri Meige published The Wandering Jew at the Salpêtrière, a study of a sample of Jewish ‘neuropathic travellers’. Then, as time went by, the fugue waned. Hysteria was ‘dismembered’ by Babinski, and the diagnosis of ‘dementia praecox’, imported from Germany, got the upper hand. The matter was settled at the Congress of Nantes: fugue, dispersed among all sorts of other diagnoses, had ceased to be an independent, discernible illness.
Why bother about this minor chapter in the history of psychiatry? Because it illustrates, in a striking way, a much broader phenomenon: so-called mental illnesses change from one place and time to another, undergo mutations, disappear and reappear. As Edward Shorter has shown, a ‘neurotic’ person was likely to have fainting spells and convulsive crises in the 18th century, some kind of paralysis or contracture in the 19th, and now would be likely to suffer from depression, fatigue or an eating disorder. As for what we call ‘psychoses’, it has long been commonplace in ethnopsychiatry and the sociology of mental illness to emphasise their cultural relativity: our pathetic paranoiacs and schizophrenics would elsewhere have been sacred or accursed beings – people possessed by the devil, prophets, shamans, ‘holy madmen’. Each age and each society produces its own type of madness, of malady of the soul, and it is pointless to try to translate one into another or make of this one the truth of another, for the cultural paradigms that give birth to them are incommensurable.
That is why, rather than speak of neurosis, psychosis or psychosomatic illnesses – all categories proper to our own era and psychiatric culture – Hacking prefers to speak of ‘transient mental illnesses’ (which I will henceforth abbreviate as TMI, to give them their proper seriousness and technicality). What matters is not whether an illness is mental (imaginary, arising from fantasy or subjective delirium) or physical (thus real, we would say, because arising from an objective causality). The real dividing line is between illnesses that vary and those that do not. Very few mental illnesses can be confidently called fixed or ahistoric (the fact that they react to this or that medication obviously doesn’t decide the question). Hacking seems to think that schizophrenia is one of the latter, but recognises that this may simply be ‘hope’ on his part. Others will say that this hope is in vain and that schizophrenia, too, will disappear some day.
If the illnesses we used to call ‘mental’ are so variable and historical, it must be because they depend on the surroundings in which they are born, grow and wither. It is a profound mistake to look for the reasons of unreason in an isolated psyche or body, or even in some ‘social construction’ of the illness, as if it did not respond to expert knowledge. In reality, a transient illness cooperates and interacts with what surrounds it. To use Hacking’s metaphor, it adapts to an ‘ecological niche’, just as a living organism adapts to a particular climate, a particular flora, a particular altitude. We should not, therefore, try to isolate one parameter of the niche to the detriment of the others, making it the central or determinant element: all the parameters – or ‘vectors’, as Hacking puts it – act in concert and any local modification immediately impels a modification of the whole.
Hacking lists four vectors that appear to him essential to the viability of a TMI. 1. The illness must be detectable as deviant behaviour. In a country obsessed with identity checks (contrôles d’identité) like late 19th-century France, Dadas and his colleagues were immediately spotted, put in jail for vagrancy, taken to hospital for observation. According to Hacking, one reason pathogenic fugue never caught on in Anglo-Saxon countries is that they did not have the same system of identity checks. Go West, young man: fugue was, literally, invisible. 2. The deviant behaviour must fit into a pre-existent taxonomy that allows it to be situated and recognised as an illness. Fugue, for example, fell neatly between hysteria and epilepsy, two illnesses which at the time were the focus of a lot of attention on the part of alienists and neurologists. 3. The illness must fit somewhere inside a cultural polarity that singles out certain behaviours as positive – ‘virtuous’, Hacking says – and others as negative or vicious. Dadas’s fugues oscillated between the new popular tourism (strongly valorised) and vagrancy (strongly devalorised). As Hacking presents it, this vector may seem a little arbitrary and far-fetched, but it touches on a profound truth. Far from being something submitted to passively, the pathological behaviour is actively chosen by troubled people to communicate both their distress and their desire to return to society. A TMI is always, in this respect, a mix of negative and positive, of abjection and possible redemption. 4. The illness must provide some release: what one could call, quoting (and correcting) Freud, the ‘primary gain from illness’. Dadas escaped his work and the overwhelming boredom of Bordeaux, just as the soldiers afflicted with shellshock escaped the trenches, and Breuer and Freud’s hysterical patients their stifling families.
As a good pragmatist, Hacking does not exclude the possibility of other vectors. As I see it, there is a very important one that he mentions only in passing. 5. There must be a clause of irresponsibility that allows the ill person to lay the ‘fault’ for his behaviour on something else – genes, a biochemical imbalance, trauma, the unconscious, the devil, the horrible-neighbour-who-cast-a-spell-on-me, or whatever. Why did Dadas run away? He couldn’t help himself. You may say that this clause of irresponsibility falls under Hacking’s second rubric, which it obviously does. But it also explains why a TMI needs to be diagnosed in order to develop. Indeed, it is only when it has been declared a true illness that it provides the sufferer with the benefits of irresponsibility. How many soldiers in the Great War would have been treated as fakers were it not for the diagnosis of shellshock? It is only because British military doctors considered the soldiers’ paralyses symptoms of a real (though psychical) disease that they escaped the firing squad – and, consequently, shellshock spread like wildfire.
Does this mean that TMIs are raise, factitious or simulated illnesses? Here we arrive at the central question of Hacking’s book: ‘Is it real?’ Hacking asked himself the same question in his recent book about multiple personality, only to add immediately: ‘I am not going to answer that question. I hope that no one who reads this book will end up wanting to ask exactly that question.’ Great books of philosophy teach us to stop posing certain types of question, or to pose them differently, and it may be that Mad Travellers is one of these. Certainly Hacking provides us with all the elements we need to understand that the question ‘Is it real?’, applied to TMIs, is pointless. The real is in a constant state of change, and it does not follow from the fact that ‘mental’ illnesses are transient that they are any less real than, say, an infectious or neurological disease.
Why would it be otherwise with TMIs? Because they are a human product, an artefact of psychiatry, of culture? But who says that an artificial product – the computer on which I write this article, for example, or a laser beam – is not real? Dadas’s travels, his migraines, his masturbation, his trances, his dreams (to which Tissié dedicated another book), all of that was perfectly real, even if it was the transient product of all sorts of contingent factors – even if it was artificial, suggested and simulated through and through. To ask if TMIs are real makes no sense, unless we suppose that only what remains identical under all its accidents (the eternal ‘substance’ of the Scholastics) is really real.
So why does Hacking insist on trying to answer the poisoned question? ‘Was hysterical fugue a real mental illness?’ he asks at one point. And his answer is ‘No.’ Why not? Hacking invokes C.S. Peirce’s cautious definition of the real: ‘The opinion which is fated to be ultimately agreed to by all who investigate, is what we mean by the truth, and the object represented in this opinion is the real.’ There is no longer any consensus on fugue among ‘all who investigate’: hysterical fugue died in 1909. We understand, of course, why Hacking insists on this strict (and slightly provocative) nominalism: TMIs exist only in ecological niches, and they depend therefore, at least in part, on the discourse concerning them. But why draw the conclusion that hysterical fugue or any other TMI is not real? It can only be because Hacking, more or less implicitly, supposes – or ‘hopes’ à la Peirce – that there are other mental illnesses that are real and non-transient, on the subject of which there could be a permanent consensus among experts. But, as he says himself, citing Peirce once again, such a hope is more an act of faith than anything else. So why not admit, once and for all, that the distinction between the permanent-substantial and the transient-accidental, the real and the artificial, the natural-objective and the social-constructed no longer works? Otherwise, how will we ever be able to understand that some people really do suffer from factitious illnesses?
It is towards this conclusion that Hacking seems to be leaning in his ‘Supplement 1’, which was obviously written after the four main chapters. This time he asks himself: ‘What ailed Albert?’ Discarding the hypothesis that Dadas’s fugues were objectively caused by a concussion he suffered at the age of eight, Hacking lists all the reasons we have for thinking that his symptoms, his dreams and the memories of his journeys were (at least from the time of his encounter with Tissié) the result of the latter’s expectations, which Dadas was only too happy to fulfil. Was Tissié interested in dreams? Dadas produced an abundance. Was Tissié interested in cycling (the subject of his second book, L’Hygiène du vélocipédiste)? During one of his dreams, Dadas, who had never travelled other than on foot, began to move his legs vigorously as if pedalling on a bicycle. It seems fairly clear that if there was wish fulfilment in this case, it was first and foremost Tissié’s.
Having come this far, Hacking could have denounced the suggestive, iatrogenic and consequently fictitious nature of Dadas’s symptoms. Generalising, he could have ridiculed TMIs in their totality: from the vapours of 18th-century ladies to our modern multiple personalities and incest survivors, from neurasthenia to anorexia, from astasia-abasia to Post-Traumatic Stress Disorder, Attention Deficit Disorder, Chronic Fatigue Syndrome and the rest. But this is precisely what Hacking refuses to do, and quite rightly so:
Clinician and patient, experimenter and subject, are so much parts of each other that the question of what ‘really’ ailed Albert Dadas late in his interactions with Philippe Tissié becomes idle, a free wheel that ceases to mesh with the course of events.
I must repeat that I do not accuse Dadas or Tissié of falsifying or faking anything. Perhaps the best word for two people in a hypnotic relationship, the hypnotiser and the hypnotised, is that the two are extremely accommodating to each other’s needs and expectations.
What Hacking says here of the mutual accommodation of the hypnotiser and the hypnotised applies equally to all the other elements of the ecological niche. Reality isn’t all on one side, fiction on the other. There is – always different and changing – a reality constructed by two, by several, by many. Tissié accommodates his theory to the odd behaviour of Dadas. Dadas accommodates his behaviour to Tissé’s theory. Patients, psychiatrists, institutions, the culture, all accommodate each other to create a TMI, just as the elements of an ecosystem accommodate each other to create a particular plant, animal or virus. Faced with such entities, the question is no longer whether it is real, but only whether it propagates or not, and how. And to what extent our own discourse – Hacking’s, mine, yours – contributes to this process.