Treating the Trauma of the Great War: Soldiers, Civilians, and Psychiatry in France, 1914-1940

Treating the Trauma of the Great War

Treating the Trauma of the Great War soldiers, civilians, and psychiatry in france, 1914–1940

Gregory M. Thomas

Louisiana State University Press Baton Rouge LSU

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LSU

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Published by Louisiana State University Press Copyright © 2009 by Louisiana State University Press All rights reserved Manufactured in the United States of America First printing Designer: Tammi L. deGeneres Typefaces: Miehle, Copperplate Gothic, Whitman Printer and binder: Thomson Shore, Inc. Library of Congress Cataloging-in-Publication Data Thomas, Gregory Mathew. Treating the trauma of the Great War : soldiers, civilians, and psychiatry in France, 1914–1940 / Gregory M. Thomas. p. cm. Includes bibliographical references and index. ISBN 978-0-8071-3436-8 (cloth : alk. paper) 1. World War, 1914–1918—France—Psychological aspects. 2. War neuroses—France—History— 20th century. 3. Veterans—Mental health—France—History—20th century. 4. Psychiatry— France—History—20th century. I. Title. [DNLM: 1. Combat Disorders—France—History—20th century. ] D524.5.T468 2009 362.2'5—dc22 2009002513

Portions of this book have appeared previously in “Open Psychiatric Services in Interwar France,” History of Psychiatry 15:2 (2004): 131–53, and in “The psychological impact of the First World War on French women,” in Women and War: A Historical Encyclopedia from Antiquity to the Present, ed. Bernard A. Cook (Santa Barbara, CA: ABC-CLIO, 2006), and are reprinted with permission.

The paper in this book meets the guidelines for permanence and durability of the Committee on  Production Guidelines for Book Longevity of the Council on Library Resources.

Contents

Acknowledgments.................................................................... vii



Introduction............................................................................... 1



1. Trauma in the Trenches....................................................... 20



2. Surviving the Home Front................................................... 71



3. The Politics of Change......................................................... 95



4. Les morts vivants................................................................. 124



5. Opening Doors for a Traumatized Nation........................... 146



Epilogue.................................................................................. 171



Notes...................................................................................... 191



Bibliography............................................................................ 227



Index....................................................................................... 253



Illustrations follow page 94

Acknowledgments Perusing obscure documents and

composing historical monographs are generally solitary tasks, but historians often rely on the intellectual, moral, and financial support of others to bring their work to fruition. I have a number of organizations and individuals to thank for their assistance with the research for and writing of this book. First, I would like to thank the organizations that made my initial research possible through their generous grants and fellowships. The Graduate Division at the University of California, Berkeley, provided me with a Humanities Research Grant that allowed me to take my first research trip to Paris. The Institut Français de Washington’s Chinard Fellowship helped me to return to Paris a second time. The Berkeley Office for History of Science and Technology’s Summer Travel Grant provided me with funding to explore the collections of the National Library of Medicine at the National Institutes of Health in Bethesda, Maryland. Grants from Berkeley’s Department of History enabled me to take an additional research trip to Paris and to devote more of my time at home to writing. Finally, research funding from the Honors College at the University of Oregon allowed me to acquire several primary and secondary sources and to contribute to this book’s production costs. Several individuals at Stanford, Berkeley, Oregon, and elsewhere also deserve special thanks. Susanna Barrows, my graduate advisor at Berkeley, gave me much of her time and energy through each phase of the graduate—and postgraduate—process. She welcomed me into her homes in Berkeley and Paris, provided me with innumerable intellectual challenges, and offered me sage advice. I am truly grateful. Margaret Anderson was instrumental in my development as a scholar. Her careful reading and critiques of my seminar papers, as well as a draft of my dissertation, were essential in helping me to im-

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prove my writing. Jack Lesch provided excellent feedback on related graduate papers and multiple drafts of my dissertation. Ann Kring, from the Berkeley Psychology Department, helped me to understand psychiatric language and ideology, and pointed me to contemporary articles to make sure this work was informed by recent research. At Stanford, my advisor Laura Carstensen guided me through my undergraduate career in psychology, providing tremendous encouragement and offering outstanding practical advice. In the History Department, Paul Robinson introduced me to intellectual history. His course on Freud led me to the epiphany that there were avenues for studying the individuals who most interested me and whose careers were given too little mention in psychology textbooks. Margo Horn was a mentor who became a good friend. Her course on the history of mental illness provided the structure for my understanding of this interesting history and introduced me to key readings in the field. In the years since that course, she has provided an incredible amount of encouragement, support, and advice on all things academic and otherwise. I thank Guenter Risse, whose courses on the history of medicine offered at the University of California, San Francisco, helped provide a strong foundation for my subsequent research. I am also indebted to Jay Winter, who provided feedback on a draft of this book, and Mark Micale, who offered astute comments on my first academic article, the content of which made its way into this book. I also thank J. P. Daughton, Hee Ko, and Emanuel Rota, all members of Professor Barrows’s dissertation group, for their thoughtful critiques of early drafts of dissertation chapters. Special thanks are also due to Elena Kouvabina, Joseph Bohling, and Kerry Marnell, all of whom provided exceptional research assistance during various phases of this project. In addition, I thank the staff of Les Archives de l’Assistance Publique in Paris (my primary research site in France), who greeted me with a smile each morning, remembered me from research trip to research trip, kindly ignored my accent, and helped me find some very interesting materials. The staff of the National Library of Medicine, especially those in the History of Medicine Reading Room, helped me to find rare documents quickly. I am also indebted to the interlibrary loan departments at Berkeley and Oregon for tracking down and borrowing materials for me from academic libraries all around the country. I thank the librarians, archivists, and acquisitions staff at Stanford University’s Green Library and Lane Medical Library, the Hoover Library and Ar-

Acknowledgments

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chives at Stanford, Berkeley’s Doe Library, the library at the University of California, San Francisco, and the University of Oregon’s Knight Library. I have been very fortunate to have access to such world-class resources close to home while researching this book. I also thank Alisa Plant at Louisiana State University Press for her encouragement, patience, excellent editorial assistance, and work in guiding this book through its various phases of production. Finally, I thank my family for their moral support through my academic career. My parents deserve particular credit for supporting my move from New Jersey to the West Coast so many years ago. My wife, Stephanie Donahue, encouraged me to go to graduate school, and she now tolerates my endless dinner-­table discussions of French psychiatry. For those and so many other things, I am eternally grateful to her. I also thank our dog Buckley and our daughter Chloe (collectively, “The Dependents”) for enhancing my level of happiness, increasing the amount of comedy in our household, and always keeping me on my toes.

Treating the Trauma of the Great War

Introduction

In late September 1920, shortly after resigning as president of France, Paul Deschanel checked himself into a private sanatorium for nervous disorders. The public was probably not surprised to learn of the former president’s whereabouts from investigative newspaper reporters. It seemed like a logical conclusion to a long, mysterious illness that had first become public knowledge the previous May, when the president was discovered wandering along railroad tracks in the middle of the night, clad only in pajamas and slippers. On May 22, President Deschanel had left Paris for Montbrison, more than three hundred miles southeast of the capital.1 He was due to make a speech there the next day at the unveiling of a statue for a senator who was killed in the war. Deschanel had been sick with the flu and had considered canceling his trip. But at the last minute, he changed his mind and left Paris by train. The train traveled slowly, either to ensure Deschanel a good night’s sleep (as one account claims) or to prevent the train from arriving too early at its destination (as another account suggests). Just before midnight, near Montargis, a railroad worker named André Radeau was checking the tracks of the Paris-Lyon-Marseille line when he spotted what appeared to be a deranged man. The stranger called out, “My friend, I am going to astonish you. You will not believe me. . . . I am the President of the Republic.” When Radeau failed to respond to this apparent madman, the stranger repeated, “I assure you that I am the President of the Republic.” 2 Radeau still did not believe the man, who claimed that he had fallen out of the presidential train. Nevertheless, Radeau took him to the house of the nearest railroad gatekeeper, Gustave Dariot.3 The stranger washed his face and hands and then asked Dariot to notify the local sub-prefect that the president had fallen from the train. But Dariot, like Radeau, was skeptical that this man was in fact the president. The stranger turned toward Dariot’s wife and asked

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Treating the Trauma of the Great War

her whether she had ever seen a picture of the president. She replied that in fact she kept a framed image of the president on the mantel, but despite some vague resemblance, the stranger did not look much like him.4 Whether or not this man was President Deschanel, Radeau and Dariot saw that he was visibly bruised, so Radeau went to find a doctor. Some time later, Dr. Guillaumont arrived, along with a gendarme. The doctor did not recognize the stranger either, but he confirmed that the man’s superficial cuts and bruises were consistent with a fall from a train.5 As the hours passed and the man tried to convince his hosts of his identity, the presidential train rolled on. Throughout the night, Radeau attempted to contact several train stations at which the train was due to stop on its way to Montbrison, but because the message that the president had fallen from the train seemed so ridiculous, it produced no response.6 It was not until morning that the president’s valet noticed that Deschanel was not in his train compartment. Word was sent back to Montargis that the president was indeed missing. Later that morning, the premier, Alexandre Millerand, as well as the president’s wife and his staff, drove to Montargis to fetch Deschanel and bring him home. When the president’s office published its official account of the incident, it portrayed the embarrassing event as an accident that, luckily, had engendered no grave consequences.7 The statement noted that Deschanel had been ill but had decided to persevere with the trip. Around 10 p.m. on the night of the train’s departure, Deschanel retired for the evening. He shut the windows to his compartment to avoid a chill. Some time before the train passed through Montargis, Deschanel, feeling warm, got up to open a window. “Seized by the strong night air,” he fell out of the window and onto the tracks. The statement insisted that the president had never lost consciousness and had maintained the composure to go to the closest gatekeeper’s lodge.8 He suffered from only light wounds, and he himself had been able to telephone the Élysée (the presidential residence) to reassure his family about his condition. When Deschanel arrived back in Paris on May 23, he was examined by two physicians, André Petit and René Le Page, who issued a statement that the patient’s wounds were light. Although Millerand tried to assure the nation by making a public statement that “the President of the Republic is, tonight, as well as you and me,” he nevertheless recommended that Deschanel take some rest at Rambouillet, the presidential summer home.9 The next day, doctors agreed with Millerand. Doctors Petit and Pierre Duval (a surgeon) reported

Introduction

3

that the president had superficial wounds to his face and left leg in addition to general aches. Like Millerand, Petit and Duval advised rest.10 History might have continued to record the incident as a bizarre accident, the result of the president’s “grippe,” the sleeping pill he had taken before bed, or even the faulty construction of the large windows in the president’s train compartment, which were intended to allow him to be seen by and to respond to throngs of well-wishers.11 It might have done so, were it not for Deschanel’s continued illnesses and the continued public pressure by journalists, politicians, and doctors for Deschanel to step down as president. Just a few days after Deschanel’s return to Paris, Doctors Petit, Duval, and Joseph Babinski—a prominent neurologist and wartime expert at distinguishing physical illnesses from imagined ones—issued a more complete medical evaluation of the president’s condition. The doctors reported no signs of serious organic injury beyond minor contusions. Still, they noted that “the state of general weakness in which the president is found, as a result of the overwork of these last years and of recent trauma, urgently requires a cure of complete rest, in the fresh air [au grand air], of some duration.” 12 As satirists put the president’s accident to verse,13 Deschanel agreed to a short repose. He left with his wife and children for the Château de la Montellerie, in Normandy, on June 4, 1920.14 On July 1, the president’s office claimed that he had completely recovered.15 That pronouncement, however, was premature: Deschanel’s condition did not improve over the summer. As politicians considered creating the post of vice president so presidential duties could be carried out even in the event of a prolonged presidential illness,16 media reports differed wildly about Deschanel’s condition.17 Some sources claimed that he was on the road to recovery, while others suggested that his condition would require him to resign. Deputies who visited the president thought that rest would cure him but admitted that he looked emaciated and tired.18 A radio report, however, said that he enjoyed considerably improved health.19 As the New York Times correspondent wrote, Deschanel’s health was one of the main topics of Paris conversation.20 In September, Deschanel suffered another embarrassing incident that reignited concern over his health and his ability to attend to presidential duties. On September 10, the president, then at Rambouillet, woke at 6 a.m., left his room, and went to the park outside. A staff employee, who was fishing out of a canal, exchanged words with the president, then turned away. When the man looked back, he saw the president in the canal, with water up to his waist.

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The man quickly rescued the president and led him back to the presidential apartment. Once in bed, Deschanel had no memory of the incident that had occurred only minutes earlier. He said nothing until murmuring, “It is cold today.” 21 Deschanel’s friends, family, and colleagues had long noted signs of his nervousness, including impatience, jerky muscular movements, and the appearance of fatigue. After his election to the presidency, that nervousness manifested itself in numerous bizarre public acts. In March 1920, Deschanel descended from his train in Bordeaux dressed in formal evening attire and top hat, even though it was before 8 a.m.22 At a ceremony in which he decorated injured war veterans, Deschanel was surprisingly passionate in embracing blind and disfigured men.23 At a lunch banquet, he astonished guests by leaving abruptly in the middle of the meal; though his entourage later explained that he left to greet the heir to the Spanish throne, the prince was not expected to arrive until much later in the day.24 In Bordeaux and then again in Menton, he picked up flowers thrown for him as he walked in the street, returning them to the women who had thrown them.25 These and other incidents might have simply been seen as eccentricities by the French public. But after the train episode, Deschanel’s behavior grew more bizarre. For example, while walking in a park with two legislators one day, he suddenly left them to try to climb a tree.26 Throughout September, demands for Deschanel’s resignation grew louder. On September 15, reporters from the French newspapers Le Figaro and L’Écho de Paris said that despite Deschanel’s brief rest, his continued poor health prevented him from conducting the usual business of the president.27 Around the same time, the president’s doctors came to the same conclusion. Doctors Petit, Duval, Babinski, and Fernand Widal (a specialist in infectious maladies and kidney diseases) concluded that the president’s health, which had been damaged by overwork and aggravated by the physical trauma of his May train accident, had yet to be ameliorated. Their medical recommendation was expressed in terms of its potentially beneficial effects for Deschanel: “The undersigned doctors have concluded the necessity of a resignation, freeing the President of the Republic from obligations and worries prejudicial to his health.” 28 Ceding to his physicians’ recommendations and to public and political pressure, the president agreed to step down. In a letter of resignation read by parliamentarians before the Chamber and the Senate, Deschanel explained, “My state of health no longer permits me to fulfill the important duties that you had entrusted to me. . . . The absolute obligation . . . to take a complete rest

Introduction

5

requires me to not delay any longer announcing to you the decision to which I am resolved. It is infinitely painful to me and it’s with a profound heartbreak that I renounce the noble task of which you have judged me worthy.” 29 What exactly was Deschanel’s illness? Speculations as to the nature and causes of Deschanel’s troubles were offered freely beginning in May 1920. His illness was often attributed to physical causes. In late May, papers reported that he had suffered a cerebral lesion due to arteriosclerosis (the hardening of arterial walls) and high blood pressure. The New York Times correspondent described the creation of this lesion as a stroke, which in turn caused a momentary syncope, or loss of consciousness due to a lack of oxygen in the brain.30 In mid-September, after Deschanel’s impromptu dip in the canal, one paper reported that his condition was in fact intermittent aphasia, perhaps in reference to his temporary speechlessness.31 Exhaustion was also commonly cited as a primary cause of the president’s health problems. In mid-September, a New York Times correspondent noted that the “stroke” in May had come at a time when Deschanel had been suffering from overwork and fatigue.32 His doctors repeatedly prescribed rest for their overworked patient, who was known to spend all day and night hard at work in his office. After Deschanel’s resignation, the press emphasized the stresses that he had endured both as president of the Chamber of Deputies (a post he held during the war) and as president of the republic. The New York Times reporter wrote, “During the many years that he presided over the Chamber of Deputies, M. Deschanel was a tremendous worker, and the nervous strain of his office has told much more severely on his constitution than he imagined or would admit. The war, too, had its effect on the man, who was at all times intensely patriotic and who felt the war tragedy in a peculiarly personal fashion.” 33 Deschanel used a pseudonym (“Duclos”) when he entered the sanatorium for nervous disorders in Malmaison, a suburb just west of Paris. Nevertheless, newspapers soon learned of the development.34 Once his location was discovered, speculations as to the causes of his illness began to include nervous and psychological elements. The New York Times correspondent who described the strains of Deschanel’s wartime government post claimed that the president had long suffered from psychiatric illness: Very shortly after he went to the Élysée, in February, M. Deschanel began to suffer from a derangement which took the form of what is called the persecution mania. He imagined that his ministers were

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withholding information from him and were not treating him with the respect due his position. For some time only Mme. Deschanel and his doctor knew the secret, but one evening, after a dinner at the Foreign Embassy, the president, losing all restraint, launched into a diatribe against his Cabinet and in the presence of a large company asserted that he was being kept in the dark about everything that was happening and a conspiracy was afoot against him.35 The reporter then went on to detail yet another incident in which both physical and psychiatric causes were implicated in the president’s strange behavior. During a drive through Saint Germain forest the previous April, Deschanel abruptly got out of his car, walked away, and returned an hour and a half later, soaking wet. Deschanel would not, or could not, explain what had happened. The reporter wrote, “Subsequent events seem to point, if not to a deliberate attempt to take his own life, to mental aberration, not unusual in those suffering a slight lesion of the brain, which leads them to risk their lives in what is a semi-conscious effort to get rid of their imaginary troubles.” 36 According to the reporter, Deschanel had sunk lower and lower into nervous depression until his resignation was inevitable. Given this emphasis on nervous strain, overwork, and exhaustion, neurasthenia might have been an apt diagnosis for Deschanel’s malady. And in fact years later, neurasthenia was one of many labels that doctors retrospectively applied to the former president. The term had been used in France since the late nineteenth century, but it was originally introduced years earlier by the American neurologist George Miller Beard to describe overworked industrialists. Though the disease was defined as a physical weakening and exhaustion of the nerves, potential symptoms could include an enormous range of physical and intellectual impairments, including mental exhaustion, memory troubles, indifference, sadness, hypochondria, muscle spasms, headaches, cardiovascular symptoms, digestive troubles, visual difficulties, and impotence.37 For Beard, modernization, capitalism, and industrialization could all contribute to neurasthenia. Because men of the higher social classes had greater exposure to the effects of those forces, they were more likely to exhibit neurasthenia. Or more accurately, doctors were more likely to diagnose bourgeois and upper-class men as neurasthenic. Though Beard envisioned neurasthenia as a particularly American illness, the diagnosis, with its somewhat positive connotations, was subsequently incorporated into British and French neurology.38

Introduction

7

The preferred treatment for neurasthenia was a “rest cure.” Developed by another nineteenth-century American doctor, Silas Weir Mitchell, the rest cure was meant to isolate the patient from family, friends, and the stresses of everyday life. Originally, patients undertaking rest cures were confined to bed, where they were fed and massaged daily.39 The sanatorium of Malmaison offered a similar sort of mild, restful treatment regime.40 Located in a twelve-acre park, the sanatorium provided an atmosphere of comfort. All the rooms had their own toilet and bath; some came with their own salon. The sanatorium, which was managed by its doctor­directors with assistance from additional staff physicians, treated patients with medical conditions, nutritional maladies, nervous disorders, psychoneuroses, and addictions. Neither severely mentally ill nor contagious patients were admitted. Therapies ranged from “repose” to psychotherapy and special medications. Private clinics for nervous or mental disorders—called maisons de santé, petites maisons, cliniques médicales, châteaux, pensions bourgeoises, villas, and other names—had been in existence since at least the end of the eighteenth century. By the early 1870s, there were twenty-five private clinics in France that specialized in treating patients with nervous or mental maladies.41 In appearance and location, those maisons de santé were a far cry from the overcrowded, rank public mental asylums, whose structures more closely resembled prisons.42 Private health clinics were stately mansions set in idyllic locales. The Château de la Vallée-aux-Loups, for example, was a historical château eight kilometers from Paris that rested halfway up a hill and in the middle of a century-old park of nearly fifty acres.43 The clinic of Mailhol, twenty kilometers southeast of Toulouse, was located on a hill in a “salubrious” region with a mild climate.44 It had a vast, shady park with a beautiful view of the Pyrenees. In the twentieth century, these private clinics offered psychotherapy in addition to a wide range of other treatments, some of which had long been used in mental asylums. Hydrotherapy, for example, a version of the baths frequently used in asylums, was common. The château of L’Haÿ-les-Roses offered hydrotherapy, electrotherapy (for weakened nerves), the application of ultraviolet and infrared rays, and a host of other treatments. Most importantly, these clinics offered rest and a retreat from the hectic world. This was the form of treatment that most benefited men such as Paul Deschanel, who, according to his doctors, had succumbed to prolonged exhaustion. Private clinics were in no way associated with the mental asylums that

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housed idiots and degenerates. Most importantly, private clinics were unlocked: patients could come and go voluntarily, discreetly, and anonymously. Deschanel was unable to avoid the press, but in the postwar period, celebrities such as Zelda Fitzgerald and James Joyce’s daughter Lucia were able to “rest” at private French clinics (or better yet, Swiss ones) without attracting much attention. When a reporter visited Deschanel at the sanatorium in late November 1920, he found the former president in a completely relaxed setting.45 As he wrote, “Nothing like a maison de santé or a clinic. A superb villa in an admirable park. It is in a comfortable sitting room, in broad, low armchairs, illuminated by a clear winter sun, that M. Deschanel receives his wife and children every day. It is next to some of the room’s wide bay windows that I saw the former president.” 46 Deschanel’s daily regime was a mild course of rest, exercise, and a diet of sustaining food. He read papers, wrote, ate, and walked two to three hours a day. According to reporter, the results of that regime were visibly obvious. In several respects, Deschanel’s case is atypical of the stories of individuals who suffered from neurological and psychological disturbances during and immediately after the war. While Deschanel’s doctors repeatedly attributed his troubles to physical causes, including the stress and exhaustion caused by serving a nation at war, soldiers and civilians were frequently diagnosed with disorders that impugned their moral character as well as their mental and physical constitution. And while Deschanel enjoyed a pleasant rest in a comfortable milieu, many troubled soldiers and civilians were sent to decrepit mental asylums, submitted to terrifying or humiliating treatments, or—in the case of soldiers—returned to the trenches. At the same time, Deschanel’s story shares many elements with the cases that appear in the following chapters. Like many soldiers and civilians, Deschanel developed a disturbance that seemed to straddle the line between physical and mental illness. Had Deschanel suffered a stroke? Was he simply physically exhausted? Or was he depressed, manic, paranoid, or deranged? Even if Deschanel’s problems had a physical origin, they seemed to cause behaviors usually found among psychiatric patients. Deschanel’s case also points to the questionable relationship between neuropsychiatric illnesses and the war. Some newspaper reporters suggested that the war caused, or at least exacerbated, Deschanel’s troubles, but there was no conclusive evidence one way or another. Clearly Deschanel had not suffered

Introduction

9

from the physical concussion of a nearby shell explosion; yet the stresses and strains of the war, said reporters, might very well have contributed to his condition. The matter of whether the war could cause illness in soldiers was one of the central questions debated by doctors during and after the war. As in Deschanel’s case, the answer was often unclear. Finally, Deschanel’s case highlights the potential power of doctors in defining the experience of their patients. For soldiers, doctors had the power to determine not only the course of treatment but also the amount of pension allocations they would receive and the degree of stigmatization they would be forced to endure. In Deschanel’s case, doctors’ pronouncements seemed to influence the course of national politics. Beyond these shared elements, Deschanel’s experience resonates on a deeper level with the stories of psychological trauma that emerged from the war. Like Deschanel wandering the tracks, taking an early-morning dip in the canal, and ultimately resigning his post, many of the soldiers and civilians who endured the physical and emotional shocks of war were left disoriented, confused, and unable to continue with their lives in a normal way. The term les morts vivants, or “the living dead,” which was used to describe disturbed soldiers sequestered in mental asylums after the war, could easily have been applied more widely to the civilian men and women who suffered from the psychological effects of the war. Like Deschanel, they survived the war, yet they inhabited a sort of liminal state between life and death, or at least between health and illness. The writer William Wiser suggested that Deschanel’s case was the harbinger of les années folles—“the crazy years” of the 1920s.47 But a study of war-­induced illnesses clearly shows that Deschanel’s malady did not so much announce a new wave of insanity that emerged only after the war. Rather, it exemplified an ongoing struggle to cope with the horrors of war that began in 1914 and lasted well into the interwar period. This book attempts to answer three primary questions: How did doctors come to understand the psychological effects of the war on soldiers and civilians? How did that understanding and the decisions that emanated from it affect the experiences of the men and women who suffered? And how did the trauma of war help to change psychiatry? From the outset of the war, neurologists and psychiatrists were faced with a fast-rising tide of neurological injuries and psychiatric illnesses in addition to an apparent epidemic of “functional” disorders—afflictions that impaired

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physical functions but seemed to lack physical causes. Doctors organized neuropsychiatric centers near the front so they could treat affected men quickly and return as many as possible to duty. While addressing the practical challenges involved in this undertaking, doctors also began to study the thousands of cases before them, endeavoring to understand whether the war alone could trigger illness in soldiers, whether it did so only in certain individuals, and whether it caused new varieties of illness. These questions generated fierce debates among neurologists and psychiatrists that referenced long-standing ideological disputes and exacerbated rifts both between the two specialties and among individual practitioners. I argue that in their quest to understand the psychological impact of the war, doctors were strongly influenced by the goals of serving a state at war, rescuing a nation in decline, and—most importantly—demonstrating the capabilities of their medical specialties. These aims had significant effects on the scientific conclusions doctors reached, the medical and legal decisions they made, and the treatment they provided. Doctors saw opportunities in the war, and they used the war and its victims to pursue long-held goals. In constructing various conceptions of what we might now characterize as “psychological trauma,” doctors demonstrated how medical science was—and is—subject to a wide range of professional, political, economic, cultural, and social forces. Doctors did not settle their wartime debates on the correct names, triggering causes, or best treatment for seemingly war-induced illnesses by the end of the conflict, but a general consensus did emerge on at least two points. First, many doctors agreed that the functional illnesses they saw were little more than conscious or unconscious attempts to shirk duty. Consequently, men with functional illnesses were granted few therapeutic or economic benefits. Second, many doctors found that functional illnesses, as well as other, more typical neuropsychiatric disorders, occurred mainly in individuals who were predisposed to disease, either by inherited defects or acquired weaknesses. Though doctors may have hoped to shed that particularly nineteenth-century model of neuropsychiatric illness, their findings continually underscored its validity. French civilians were in no way immune to the stresses and strains of war, and, not surprisingly, many French civilians succumbed to those stresses and strains, and became ill. A small number of wartime doctors studied the development of mental and neurological illnesses among civilians. Could war trigger mental illness in civilians? The study of war-induced illnesses in civilians

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11

was integrated into an ongoing discourse on the influence of major upheavals on mental health that stretched back through the long, tumultuous nineteenth century. While some prominent nineteenth-century researchers believed that wars, natural disasters, and sociopolitical crises could generate mental illness in otherwise normal individuals, World War I doctors were forced to conclude otherwise. As with the study of soldiers, doctors evaluating civilian problems that resulted from the First World War found that mental illness developed mainly in civilians who were predisposed to it. No one could deny that the war was stressful and depressing. But doctors found that most people seemed to withstand the strains of war without deteriorating into madness. Because civilians were generally not subjected to the physical trauma experienced by soldiers, civilian cases should have provided important information for doctors hoping to isolate the effects of physical trauma on the minds of patients. But the studies of war-induced disturbances in civilians and soldiers remained largely distinct. The study of civilian illnesses was undertaken by fewer doctors and greatly overshadowed by the study of trauma in soldiers. For doctors, civilian cases lacked both the urgency of the wartime context and the value to the nation that might be derived from successfully—heroically— curing soldiers. The conceptions of psychological trauma that doctors constructed during the war, and the medical decisions that those conceptions produced, had immediate, deep, tangible, and often negative effects on the traumatized. Diag­ nostic labels created and applied by doctors dictated how soldiers would be treated and whether they would be discharged from service or returned to duty. Doctors deepened the impact of their decisions on soldiers’ lives by inserting themselves into attempts to revise the military pension law and its accompanying disability tables. When the war began, the military pension system was a jumble of outdated laws and piecemeal revisions. Legislators recognized the need for substantial change and mounted initiatives to create a new pension system. Throughout the war, neurologists and psychiatrists insisted that their expert input was essential in the creation of that system. Only experts, they argued, could determine which diagnoses warranted pensions and to what degree those illnesses might impair normal functioning. While the new pension law of 1919 promised to make it easier for sick and wounded soldiers to receive disability pensions, the input of the neuropsychiatric community in fact served to prevent many psychologically traumatized men from gaining similar benefits.

12

Treating the Trauma of the Great War

While I suggest that neurologists and psychiatrists were successful in their attempts to influence pension law reform, I also show that some psychiatrists were nevertheless incensed by the law of 1919, which they believed failed to take into account their wartime research and their ability to cure patients. They campaigned to change the law through the 1920s and 1930s. The uphill battle that they faced shows at once doctors’ strong drive to exert their professional muscle and legislators’ relative lack of interest in helping soldiers with psychiatric disturbances. How did pension law reform, individual pension verdicts, and the variety of other medical decisions pertaining to psychologically traumatized soldiers actually affect the lives of those men and their families? Though all sick and wounded soldiers struggled to make ends meet with the meager pensions provided by an economically ravaged French state, psychologically traumatized men suffered more. War hysterics received no pensions, while men interned in mental asylums saw their pensions evaporate through the payment of institutional fees. In addition to portraying the plight of these morts vivants and their families, I trace the attempts by soldiers’ family members and their advocates to revise the pension law in order to improve the level of institutional care provided to veterans and to increase the amount of compensation awarded to veterans and their families. As it was with doctors who hoped to change the pension law, these campaigns mounted by veterans’ families and their advocates were slowed not only by legislative torpor but also by the low political value of serving the mentally ill. Though doctors are the primary agents of this book, I also explore the stories of soldiers and civilians who were traumatized by the war. Those stories have been gathered from a wide range of medical and military sources, including professional journals, monographs, dissertations, military dispatches, departmental administrative reports, and hospital ledgers. Contemporary press reports served as important complementary sources. I have used the most prominent veterans’ journal extensively to examine the effects of doctors’ decisions on the lives of ex-combatants and their families, and I have used the popular press to help assemble President Deschanel’s case. The answer to the question of how the trauma of war changed psychiatry is, on the surface, simple: it didn’t. The history of psychiatry throughout this period reveals more continuity than change. Though doctors explored new causal models for illness, prior models remained largely intact. Though they created some new diagnostic categories, many doctors subsequently argued that the war did not create any new forms of illness.

Introduction

13

If the war did not fundamentally alter psychiatric conceptions of etiology (causes) or nosology (the classification of disease), it did, however, help to precipitate changes in psychiatric practice. A combination of demographic, economic, and administrative factors created an administrative and political climate favorable for change. For years before the war, “mental hygienists” had campaigned unsuccessfully for the improvement of asylum conditions, the introduction of new modes of psychiatric treatment, and the implementation of an array of prophylactic (“hygienic”) measures that might help prevent illness and fortify the mental health of a French nation in decline. In the postwar years, the messages of mental hygienists were much better received by civil administrators, national politicians, and the public. With the healthcare system in disarray, little money to rebuild damaged buildings, and an apparent swell in the number of individuals needing care, administrators and politicians were more willing to consider alternatives to the existing system of psychiatric assistance. Psychiatric reformers succeeded in making changes not just because conditions were ripe but also because they capitalized on those conditions. Mental hygienists fine-tuned their rhetoric, highlighting the ways in which hygienic programs—and in particular “open” psychiatric services, which operated more like medical hospitals than locked asylums—could solve a host of challenges facing postwar France. In making their case, these psychiatric reformers helped perpetuate the perception that France was a traumatized nation, desperately in need of psychiatric assistance. They insisted that there was an army of individuals who needed medical help to rebound from the horrors of war. Reestablishing the psychic strength of French civilians, they said, was essential to reestablishing the nation’s collective vitality. Only psychiatrists, as purveyors of a reinvigorated medical specialty, could help with that effort. In truth, there is little evidence that psychiatric illnesses were more prevalent after the war than before it. But that mattered little. Psychiatric reformers insisted that the war had strained the mental health of French citizens. And few French men and women seemed to disagree. The creation of open psychiatric services is an important moment in the history of psychiatry. These services sounded the death knell of the asylum and opened the way for a more medicalized approach to mental illness—an approach that psychiatrists had hoped to follow since the specialty’s inception. Open psychiatric services also helped to lower the threshold for the decision to seek psychiatric care. Individuals with milder illnesses, such as acute depression, which in the past might not have prompted them to seek help, came

14

Treating the Trauma of the Great War

for treatment in rapidly increasing numbers. French citizens may have shown great fortitude and endurance during the Great War; but after the conflict’s end, when given new opportunities for psychiatric assistance, they increasingly sought help for their troubles. Though I focus primarily on changes within psychiatry, the field of neurology plays an essential role throughout this book. As I explain in Chapter 1, psychiatry and neurology were closely related specialties. In addition to sharing similar medical training and overlapping in the study and treatment of several diseases, psychiatrists and neurologists held similar goals for their specialties. Both groups wanted to improve the status of their fields by strengthening the alignment with medicine proper. This book supplements the multiple historiographies that its subject intersects, including the history of shell shock; social, cultural, and political histories of France; the history of veterans; and the history of psychiatry. Amid the vast historical literature on World War I, numerous studies focus on shell shock.48 The disorder has been examined as part of studies on broader categories of disease, such as hysteria, neurosis, psychosomatic illness, and trauma,49 and it has been referenced in histories of psychiatry and neurology.50 Many of the historians, psychologists, sociologists, and literary critics who have written about shell shock undoubtedly have been drawn to the subject for its highly symbolic content. Some writers have suggested that the paralyses, contractures, and aphonias that defined shell shock demonstrated the war’s power to dehumanize and emasculate soldiers.51 Others have suggested that the diag­ nosis of shell shock (or hysteria) reflected the dehumanizing and emasculating powers of doctors over their patients.52 Most of the English-language histories of shell shock have focused on its manifestations among British troops. The German case has only recently been uncovered.53 The French case, however, has been less well researched, and very few studies in any language devote much space to it.54 Beyond Marc Roudebush’s 1995 dissertation, which focuses primarily on wartime neurologists and functional illnesses among soldiers, writing on war-induced neuro­ psychiatric disorders in France has been limited to brief references by psychiatrists charting the history of psychiatry and by historians analyzing the gender implications of hysteria’s use as a diagnosis for men. This book endeavors to place shell shock in the context of a wider range of neurological and psychiatric disorders experienced by soldiers.55 In France,

Introduction

15

the majority of neuropsychiatric patients met a very different fate than that of war hysterics, who have been the focus of most scholarship. Severe psychiatric cases, for example, were spared the severe electrical shocks that doctors used to jolt hysterics out of their “malingering” states, but they suffered nonetheless. Many were sent to public asylums, where they were generally abandoned. By contrast, patients with transient psychopathies that resulted from head wounds were treated with dignity in medical hospitals and subsequently released. The variety of diagnoses and treatments given to patients with these non-hysterical conditions help to illuminate the ideology and practice of neurology and psychiatry during and after the war. Moreover, the stories of patients with these conditions show the far-reaching effects of war on human minds and bodies. In addition, this book extends the investigation of wartime trauma well beyond the trenches. Most historians who have written about the psychological effects of war have concentrated on soldiers. Yet civilians suffered enormous psychological strains during and after the war as well. Examining those strains from a medical vantage point complements existing studies that evaluate the economic, political, and—in a general sense—emotional challenges that faced civilians during the war.56 While this book shows that some civilians were so deeply traumatized by the war that they developed psychiatric illnesses, it also reveals that there is no evidence of a widespread explosion of mental illness during or immediately after the war. Contemporary doctors might have been correct in concluding that most of the civilians who developed mental illness during the conflict were predisposed to it. In any case, there would have been few options for treatment during the war even if there had been a large number of civilians in need of psychiatric assistance. Some mental asylums were militarized to accept soldiers in need of either general medical or psychiatric care. Others were closed or were forced to offer curtailed services due to staff shortages. Most civilians adapted and endured—they had no other choice. Since this book stretches into the postwar period, it complements the growing number of works that discuss the postwar plight of physically and psychologically traumatized veterans and that examine the significance of shell shock in postwar culture. Scholars have shown how the prevalence of shell shock among British soldiers changed conceptions of insanity and challenged traditional values; how social, cultural, and political constraints in Russia kept the number of reported shell shock cases among soldiers and

16

Treating the Trauma of the Great War

civilians there in check; how war-induced psychiatric disorders in France served as inspiration for interwar-era Surrealists; and how the American Legion secured specialized care for neurotic American veterans in the 1920s.57 In a survey of twentieth-century military psychiatry, one historian has shown how the prevalence of psychiatrically disabled British, American, and German veterans engendered institutional and professional changes in those countries.58 Recently, a French historian has investigated the long and complicated history of mourning, denial, and delusion, using the case of a mentally disturbed and amnesiac soldier—whose story is also recounted briefly in this book— and the numerous attempts by French families to claim him as their own.59 This book further supplements the histories that examine French society, culture, and politics in the interwar period. Historians have analyzed a wide range of materials from the 1920s and 1930s to better understand how the psychological wounds of war altered the choices, opinions, and behaviors of the French people.60 This book investigates evidence from French medicine in an attempt to corroborate those social, cultural, and political manifestations of trauma with the clinical record. This work confirms the arguments of some historians and challenges others to distinguish more carefully cultural representations of trauma from medical ones. This study also contributes to the historiography of World War I veterans.61 The story of the challenges that faced psychiatrically disabled veterans offers an interesting counterpoint to the stories of physically wounded men and ablebodied veterans. In France, advocates for mentally disabled men (who generally did not speak for themselves) lobbied strenuously for increases in pension allowances, as did their physically disabled counterparts. Yet while physically disabled men were viewed as national heroes who deserved whatever financial compensation the nation could afford, mentally troubled veterans were largely ignored. This book underscores the unique hurdles encountered by psychologically troubled veterans and their families as they sought equity with their physically injured brothers in arms. Although studying memory has become a popular means to approach histories of war and veterans,62 memory is not a central theme in this book. As villages, cities, and nations throughout Europe erected monuments in town squares and created cemeteries with neatly lined gravestones to shape the memories of the dead according to political or national aims, psychologically disturbed veterans and civilians did not construct “realms” of collective memory. And while individual memory is a primary element in today’s conception

Introduction

17

of trauma, it did not play a major role in the discourse on war-related disorders among French doctors during or after the war. For the most part, doctors did not ask patients about their memories, nor did they point to memory as a cause of or even an aggravating factor in illness. Even doctors who had written about memory before the war failed to revive those discussions during the conflict. Except for the study of amnesia following physical injuries (which did garner interest among doctors), the role of memory in neuropsychiatric disorders was a question more for psychologists and fringe psychoanalysts than mainstream neurologists and psychiatrists, and consequently few French doctors concerned themselves with it. The story of traumatic memory in France from the perspective of the patient rather than the doctor still needs to be written. The case histories and newspaper articles that provide the narratives of trauma in this book do not tell the full story of patients’ traumatic memories, but they do hint at the history that might be uncovered. Those sources suggest that individual memories of the war were persistent irritants for French veterans and civilians—irritants that prevented many individuals from overcoming their psychological pain and returning to normal life. By examining the ideology and practice of French psychiatry during and after the war, this book uncovers one of the very few under-researched segments in the history of that medical specialty. Since the 1960s, when Michel Foucault published Folie et déraison: Histoire de la folie à l’âge classique (recently published in an unabridged translation as History of Madness), the history of French psychiatry has been overrun by philosophers, sociologists, historians, and psychiatrists, all weighing in on Foucault’s cutting critiques of psychiatric power.63 Despite the density of this historical field, nearly all of it has been confined to the nineteenth century. To the extent that the historiography of French psychiatry has reached into the twentieth century, writers have generally focused their studies on the development of psychoanalysis.64 Until recently, the history of non-psychoanalytic psychiatry in France during the early twentieth century was told only as part of a general history of psychiatry.65 However, several French writers have begun to examine key developments in French psychiatry during the interwar years, including the emergence of the mental hygiene movement—a topic that is central to the story of French psychiatry’s interwar history and, more specifically, to the story of how trauma changed psychiatry.66 This book connects strongly with histories that focus on the professional

18

Treating the Trauma of the Great War

challenges and aspirations of neurologists and psychiatrists. In particular, this study dovetails with the work of the historian Ian Dowbiggin. In his book Inheriting Madness, Dowbiggin shows how hereditary thinking, and especially a model called degeneracy theory, gained popularity among nineteenth­century French asylum doctors as they attempted to explain the riddles of mental illness in the absence of clear somatic findings.67 Degeneracy theory, which is described more fully in Chapter 1, held that inherited scars and constitutional weakness (acquired either through illnesses or immoral behaviors) might be passed down through successive generations, and that the accumulated effects could cause the degeneration of families. Dowbiggin concludes his book with the decline of degeneracy theory in the early twentieth century. He argues that by then, degeneracy theory no longer held the same value for neurologists and psychiatrists, who were developing new treatments for functional disorders, making some important scientific gains, and—in the case of psychiatrists—shedding their connections to the decrepit asylum. The decline of degeneracy theory, writes Dowbiggin, was also hastened by a nationalist revival and the emergence of social programs that promoted education and welfare for the poor and working class. Doctors no longer wanted to portray French men and women as degenerates. There is no question that early twentieth-century neurologists and psychiatrists hoped to break free from nineteenth-century models of illness. But as this book shows, the idea that inherited or acquired weaknesses might predispose individuals to illness did not lose ground during or after the First World War. In fact, just the opposite happened. Doctors concluded time and time again that illnesses appeared almost exclusively in people who were predisposed to it. This finding was so widespread and undeniable that it forced doctors to question another causal model, advanced by some of French psychiatry’s founders, which held that wars and other sociopolitical upheavals might create disturbances in even the healthiest individuals. Though this book subtly adjusts the end of Dowbiggin’s story, it strongly endorses the emphasis that he and the historian Jan Goldstein place on the role of professional goals in the history of medicine. Like Dowbiggin and Goldstein (whose book Console and Classify traces the early development of the psychiatric specialty), I argue that understanding professional challenges and goals is essential for understanding changes in neuropsychiatric thought and practice. Doctors adopted certain ideological positions, insisted on participation in legislative projects, and lobbied for institutional change in large part because of their tenacious quest to improve the status of their specialties.

Introduction

19

Finally, this book adds to the growing literature about histories of trauma.68 This study reinforces the argument that concepts such as trauma, as well as hysteria, depression, and a wide range of other neuropsychiatric labels, are human constructions. The debates over the causes, diagnoses, proper treatments, and correct compensation for war-induced disturbances highlight the array of factors that can contribute to the construction of medical conceptions. Whether labeled as “trauma” or some other term, the psychological effects of the First World War clearly were far-reaching in France. They extended for miles behind the lines, where mothers and sisters suffered the losses of loved ones; they touched villages and farms, where veterans struggled to regain a sense of normal life; they were felt in mental asylums throughout France, where thousands of disturbed men and women languished for years after the armistice; they were recognized in postwar departmental offices, where administrators heard petitions to open new psychiatric facilities to accommodate a supposed influx of psychiatric casualties; they reverberated in the chambers of parliament, as legislators argued over the value of soldiers’ physical and mental contributions to the nation; and they even reached the presidential palace, where a politician’s frayed nerves got the better of him. The study of traumatic experience must begin, however, where medics retrieved the war’s first traumatized souls—in the mud of the trenches.

Chapter 1 Trauma in the Trenches

Near the Belgian border in October 1914, an artillery shell exploded close to R., a thirty-six-year-old French infantryman, throwing him a distance.1 He was quickly taken to a medical station, where his condition was evaluated. Blood was seen coming from his mouth, and he was unable to speak. Nevertheless, he somehow indicated that he felt weakness on his right side. R. was transported to a hospital behind the lines, where he stayed for three weeks. Doctors there diagnosed him with right hemiplegia (paralysis of his right side), contracture (a tightening or shortening of a muscle), and mutism (the inability to speak). R. was subsequently transferred to another hospital, where he was given electrical stimulation to try to revive his right side. Gradually, he recovered the use of his right arm, but his leg continued to exhibit contracture and anesthesia (loss of sensation). The leg problems and mutism were subsequently deemed “functional”; that is, the disturbances seemed to disrupt functioning, but no organic injuries could be found. Functional illnesses, whose symptoms ranged from paralysis and anesthesia to mutism and deafness, plagued French neurologists and psychiatrists from the beginning of the war. While some doctors believed that these strange disorders were the result of physical injuries due to nearby explosions, such as the one R. endured, others contended that they were fictions generated in the minds of malingering men. Some British doctors lumped these troubling conditions into a syndrome called “shell shock,” since their initial impression was that symptoms were correlated to the physical effects of shell explosions. The French, meanwhile, concocted their own labels, including obusite (from obus,

Trauma in the Trenches

21

meaning “bomb”), “commotional syndrome,” “war neurosis,” and “battle hypnosis.” Some French doctors (like many of their German counterparts) simply referred to functional illnesses as “hysteria”—a term with a long history whose use during the war reignited medical debates about the disorder, and also served to humiliate soldiers. Hysteria, which straddled the line between neurological and psychiatric disorders, was not the most prevalent neuropsychiatric condition among the troops. Psychiatrists saw cases ranging from depression, anxiety, and mania to precocious dementia, mental retardation, and alcoholism (which was included among mental illnesses). Neurologists meanwhile observed a wide variety of confirmed, physical injuries of the head and nervous system. Hysteria was, however, one of the more challenging disorders that doctors faced. In the first place, it was difficult to distinguish from other illnesses. The symptoms of hysteria could mimic the symptoms of a number of neurological and psychiatric disorders. Moreover, in many cases, the symptoms of hysteria appeared along with true, confirmable physical injuries. Hysteria also had the potential to become contagious. Many neurologists and psychiatrists believed that hysterical “suggestions” could spread among troops at the front, weakening morale, destroying discipline, and inspiring an epidemic of neuropsychiatric cases. Doctors and military administrators alike understood that halting the spread of hysteria was crucial to retaining the maximum number of soldiers who were fit and ready for battle. With his symptoms persisting, R. was transferred again, this time to the Salpêtrière—a large and old public hospital in Paris that had been the professional home of Philippe Pinel, the early nineteenth-century founder of French psychiatry, and Jean-Martin Charcot, the late nineteenth-century neurologist and expert on hysteria. In the 1870s and 1880s, Charcot attracted students from across France and beyond, who came to observe his theatrical presentations of hysterical patients. Hysteria had once been considered an affliction relegated to women, whose womb was thought to wander physically throughout the body, causing contortions, spasms, and other strange behaviors. But Charcot and his students came to understand hysteria as an essentially neurological illness to which individuals (male or female) could be predisposed through inherited weaknesses. At the Salpêtrière, Charcot defined the disease precisely, enumerating observable, regular phases of hysterical attacks. Charcot had his detractors, but under his direction the Salpêtrière became a renowned center for the investigation of hysteria and a range of other neuro-

22

Treating the Trauma of the Great War

logical disorders. The Salpêtrière was a civilian hospital in peacetime, but it was one of many civilian institutions to open its wards to military men early in the First World War. In January 1915, administrators doubled the number of beds available for soldiers afflicted with nervous disorders, from 72 to 144. Just one month later, 250 additional beds were requisitioned to accommodate the rising tide of patients.2 At the Salpêtrière, R. was evaluated by Joseph Jules Dejerine, chief of the hospital’s neurology clinic. Dejerine held Charcot’s former chair as professor of neurology, but he rejected the master’s standardized model of hysteria, instead favoring a more individualistic approach.3 According to Dejerine, the symptoms, signs, and causes of hysteria were subtly different in each patient. Dejerine also stood opposed to one of the more popular notions of hysteria among wartime neurologists. Joseph Babinski, a former student of Charcot, had tried to overturn his master’s views in the early 1900s. Babinski attempted to convince his fellow neurologists that hysteria had effectively been “dismembered.” He held that doctors had attributed most hysterical symptoms to other disorders, ranging from organic, neurological diseases to psychological syndromes. What remained was tantamount to malingering. Babinski renamed the rump of the disease “pithiatism,” meaning “curable by persuasion.” For Babinski, pithiatism was the result of false suggestions implanted in the minds of patients. It was not the result of organic lesions, nor did it affect the nervous system physically. According to Babinski, pithiatic symptoms could be forced to disappear by strong counter-suggestions made by an imposing, authoritarian doctor. Babinski had tried for years before the war to supplant hysteria with pithiatism. By the outbreak of the war, pithiatism was still not universally accepted in the medical community, but the wartime crisis of functional illnesses encouraged many neurologists to reconsider the value, if not the validity, of the model. Dejerine shared neither Babinski’s causal assessment of functional disorders nor his recommendations for their treatment. Dejerine argued that emotions, not suggestions, were at the center of hysteria and other neuropsychiatric disorders. He believed that sudden emotional shocks, such as those frequently suffered by soldiers, could trigger the development of hysteria, though only in predisposed individuals. He thus saw little utility in using counter-suggestion, or “persuasion,” in treating patients, believing it was potentially abusive. In fact, Dejerine found that most physical, pharmacological, and hypnotic therapies were useless against hysteria.

Trauma in the Trenches

23

Dejerine’s recommended treatment regime for hysteria began with isolation—a tactic that had been used to treat the mentally disturbed for more than a century. The patient was removed from the stimuli that evoked the extreme emotional reaction. The doctor then began a form of psychotherapy. Doctor and patient met and, through conversation, rooted out the underlying causes of the disease. For Dejerine, this doctor-patient interaction was meant to be similar to a religious confession, in which the patient “confessed his entire life.” 4 The doctor was supposed to spend adequate time with each subject, listening attentively and gaining the patient’s confidence. According to Dejerine, this method was more likely to prevent relapses than the methods advocated by Babinski and his supporters. The type of psychotherapeutic treatment applied by Dejerine was rare in France during the First World War. While the idea of psychotherapy was not foreign to French medicine (Pierre Janet had introduced analytic therapy before Freud), in-depth psychotherapy did not serve the needs of the military. It was not a rapid cure, and the military needed French doctors to send men back to the front as quickly as possible. When R. arrived at the Salpêtrière, Dejerine ran a battery of physical tests to evaluate the soldier’s injuries. For R.’s leg, Dejerine tested range of movement, muscular strength, reflexes, and sensitivities (that is, the ability to feel pressure, pain, and temperature). The cutaneous reflex on the sole of R.’s allegedly anesthetized foot was absent—a fact that signaled the possibility of an organic injury. A lumbar puncture was performed, but the results of tests on the spinal fluid were negative. Another doctor then examined R.’s vocal cords with a laryngoscope and found them to be functioning normally. The laryngeal reflex was absent, however. The examining doctor could touch R.’s larynx without provoking the slightest pain or cough. Dejerine also collected personal information from the patient, which he believed could offer clues to R.’s functional leg paralysis. The interview was conducted despite R.’s continued inability to speak. Dejerine noted: “The patient is completely aphonic, unable to emit a single word, a single sound, but only a halting wheezing, a sort of noise of a jet of vapor, corresponding to the words that he wants to pronounce. . . . He writes all of his history and responds to questions by writing.” 5 Dejerine learned that R. was a farmer, husband, and father of three children, all of whom were in good health. There were no specific personal antecedents that might have suggested R. was suffering from a purely psychological disturbance, but the doctor did note that R.’s father had

24

Treating the Trauma of the Great War

been an alcoholic, and that R. and his mother (perhaps consequently) had led “a rather unfortunate life.” Moreover, R. admitted that he had always had a “nervous, impressionable temperament,” a fact that Dejerine believed was connected to his functional disturbances.6 As Dejerine described him, R. was “very emotive, crying easily, and trembling all over when he speaks [sic] of his wife and his children.” 7 The patient was isolated and treated by psychotherapy for two months with no effect. Then, during the third month, there was some improvement. R.’s symptoms began to disappear, and both his cutaneous foot reflex and laryngeal reflex returned. By the end of the third month, R. was cured of his “hysterotraumatism,” as Dejerine called it, and was able to leave the hospital. He was probably sent back to the front. This case history, which Dejerine presented to the Neurology Society of Paris in February 1915, along with four others that featured the abolition of the cutaneous plantar reflex, provoked an immediate and acerbic response by Babinski. An authority on the cutaneous plantar reflex who developed a reflex test that still bears his name, Babinski said Dejerine’s study was “far from being convincing.” 8 It was a typical comment from Babinski, whose firm, authoritarian style of treating pithiatics was a reflection not only of his medical ideology but also of his personality.9 According to Babinski, Dejerine failed to distinguish reflex movements from voluntary ones. Consequently, he did not successfully show that the reflex had been abolished and did not prove that hystero-traumatism could cause that abolition. Dejerine offered a rebuttal, but the debate was far from settled. In R.’s specific case, many questions were left unanswered. Were R.’s disturbances truly the result of physical injuries caused by an explosion? Were they instead physical manifestations of the emotional, psychological shock that he no doubt also suffered? Or was R. faking to win a reprieve from the front line? Did R.’s emotional character contribute to the development of his symptoms? And what was responsible for his cure? Neurologists and psychiatrists faced similar questions on a daily basis. Confronted with an apparent epidemic of functional disorders as well as a full array of other maladies, doctors struggled to understand the role of the war in the genesis of illness. Could the war trigger illness in soldiers? Did it only do so in certain individuals? How prevalent were war-induced diseases? Did those diseases constitute new types of illness? What should be done to cure them? What was the responsibility of each individual in the emergence of disease?

Trauma in the Trenches

25

Doctors believed that providing answers to those questions was essential in assisting with the war effort and achieving a range of professional goals.

Psychiatric War Aims Doctors’ eagerness to serve their state at war should not be surprising. The war was greeted with great enthusiasm by many Europeans. Some believed that a little fighting would provide a revitalizing experience that could help civilization overcome its perceived exhaustion and decline. The war might simultaneously help to cull the weak and degenerate, since only the strong would survive. It also strengthened nationalist sentiments that had been percolating over the course of the nineteenth century. In France, those sentiments had contained a strong anti-German element ever since the country’s humiliating defeat in the Franco-Prussian War of 1870–71. Doctors were in no way immune to this nationalistic outlook. The writing of French neurologists and psychiatrists before, during, and after World War I betrayed strong nationalistic attitudes. An editorial published in 1915 by Victor Parant presented the extreme example. Parant wrote that even before the Germans had invaded French territory, “Germany had for a long time tried to invade the world of ideas, to submit [the world] to what it called its culture, superior culture. . . . It wasn’t far from having succeeded.” 10 According to him, German psychiatry took part in that invasion: “German psychiatry was constituted suddenly, abruptly. Abruptly, it burst onto the scene, trying to substitute itself . . . for all that existed before it. These behaviors were analogous to those of the military attack. . . . And like the military attack . . . [German psychiatry] amassed ruins around itself, it gave birth to anarchy, psychiatric anarchy.” 11 For Parant, the war against Germany presented a critical moment for French psychiatrists: “Has not the moment come for those [psychiatrists] who have let themselves be influenced and seduced by German doctrines to examine whether they have not been in error?” 12 Has not the moment come to “cut short the invasion of German psychiatry and to bring back French culture and psychiatry?” 13 Even those who did not adopt the same sort of dramatic language held similar attitudes. French doctors were well aware that French science and medicine had been eclipsed by German science and medicine through the second half of the nineteenth century. Of course, most French psychiatrists did not believe that German psychiatry had appeared out of the blue, as Parant sug-

26

Treating the Trauma of the Great War

gested. Instead, they claimed that the roots of German psychiatry could easily be found within French psychiatry. For example, when the German psychiatrist and professor Emile Kraepelin defined dementia praecox as distinct from manic-depressive psychosis (an important moment in the history of psychiatry), many French doctors claimed he was offering nothing new to the field.14 French categories such as “démence précoce” and various versions of “degenerative folly” had already captured the sense of dementia praecox. Moreover, manic-depressive psychosis, said French doctors, had long been understood in France. Referring to the “truths that come to us from beyond the Rhine,” two French doctors wrote that “manic-depressive psychosis is, one should say, the most French of the conceptions from the professor of Munich.” 15 In addition to serving the practical aims of a state at war and supporting a national endeavor, doctors had several additional motivations for participating in the war effort. First, neurologists and psychiatrists hoped to use the soldiers that they encountered as material to study disease and to contribute to medical knowledge. The war provided a seemingly endless supply of cases, and doctors used those cases for hundreds of medical studies presented at professional meetings, published in medical journals, and collected in monographs. According to Gustave Roussy, who supervised a regional collection of neurological and psychiatric centers during the war, the abundance of functional nervous disorders presented important opportunities for study and experimentation. In the short term, he believed, this profusion of disorders would enable doctors to fine-tune their treatment methods and therapeutic environments to optimize results. In the long term, it would help doctors better understand the causes of hysteria.16 In a study on anxiety, the doctors Albert Devaux and Benjamin Joseph Logre wrote that the war’s violence, duration, and simultaneous impact on millions of individuals allowed for “incomparable psychological experimentation.” 17 Paul Voivenel, a doctor who studied the psychology of soldiers, wrote in reference to his own study of morbid emotivity that the war provided a “grandiose laboratory experience.” 18 As Roussy suggested, doctors were eager to try new concepts for the organization of their medical facilities. Neurologists wanted to test whether separating men within specialized centers according to the type and severity of their injuries would help streamline therapeutics. Psychiatrists hoped to show that “open” psychiatric services, which operated more like medical hospitals than locked asylums, could offer benefits to patients by providing active treatment and removing the social stigma of commitment. Both neurologists and psychi-

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atrists hypothesized that treating men early, near the front, before symptoms became too deeply rooted, would improve cure rates. In many cases, scientific pursuits were driven by the quest to provide additional support for individual etiological (causal), diagnostic, and therapeutic positions in long-standing debates. For Babinski, the war provided an opportunity to revive his notion of pithiatism. Babinski had first attempted to redefine hysteria as pithiatism in a paper presented to the Neurology Society of Paris in 1901.19 But by 1908, when the society finally voted on the matter, Babinski had not won over his peers.20 The society pronounced that while hysteria was often produced by suggestion, the term “pithiatism” should not be adopted in place of hysteria. In the years following that decision, Babinski did not give up his quest. His unflagging commitment to pithiatism was probably driven not only by steadfast medical beliefs but also by deeper, more personal, motivations. He had been one of Charcot’s favorite students, but after Charcot’s death, he lacked the requisite support from prominent doctors to succeed at the competitive examination that would have enabled him to teach at a university. Consequently, he was never eligible for Charcot’s chair in neurology, though he might have felt entitled to it.21 Babinski claimed to have harbored critiques of Charcot’s ideas while he was still a student,22 but his ongoing battle to supplant hysteria with pithiatism might very well have been motivated by a determination to distance himself from Charcot’s intellectual lineage or to build his legacy in neurology outside of academia. The prevalence of functional disorders among troops breathed new life into Babinski’s campaign. He now had hundreds of cases that he could use to support his claims. More importantly, the war provided urgency to the discussion. While it had taken six and a half years for the Neurology Society to vote on Babinski’s 1901 proposal, there was now no time for delay. Quickly defining the causes and proper treatment of functional disorders was essential for the war effort. The war also provided opportunities for neurologists and psychiatrists to bolster the status of their medical specialties. Psychiatrists in particular were eager for those opportunities. Largely relegated to tending to incurables in public insane asylums, psychiatrists desperately wanted to prove that they could address important practical questions—such as the influence of the war on mental illness—and then create institutions and therapies that could effect cures. Both neurologists and psychiatrists hoped to strengthen the ties

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between their fields and scientific medicine. Decades earlier, European physicians and scientists, including Louis Pasteur, Joseph Lister, and Robert Koch, had shown that the application of germ theories to medicine could help protect individuals—and nations—from disease. French neurologists and psychiatrists hoped to show that their fields could similarly help their nation by recouping as many men as possible for the war.

The Neuropsychiatric Community Psychiatrists and neurologists often worked side by side during the war, but neurology and psychiatry had developed distinctly in France and, despite prewar efforts toward integration, important divisions continued to separate the fields.23 Psychiatry in France was born in the first part of the nineteenth century, when doctors such as Pinel and his student Jean Étienne Dominique Esquirol began to medicalize the charitable hospices and prison-like hospitals that housed the insane.24 Previously, institutions such as the Salpêtrière and Bicêtre in Paris were little more than permanent holding pens for vagrants, drunks, and idiots. Pinel and his followers segregated the insane from the other inmates, unchained them (symbolically, if not literally),25 and began to provide individualized treatment, which they insisted could cure patients who previously had been considered hopeless. Pinel’s treatment model promised a new gentleness toward patients, in clear contrast to the chains that had previously bound them. Yet as the philosopher Michel Foucault and others have argued, Pinel’s traitement morale may have simply traded physical confinement for psychological manipulation.26 In Pinel’s method, the doctor acted as an authority figure, constantly monitoring his patients’ behaviors and helping guide them back to self-control and civilized behavior by requiring them to internalize socially acceptable values.27 Though the therapeutic benefits and ethics of the traitement morale now seem questionable, its practice clearly helped doctors colonize the madhouse, which previously had been the domain of clergy and civil administrators. As the historian Colin Jones wrote, “The doctor had gained admittance to the asylum not because of the power of his drugs but because of the strength of his personality in applying the so-called ‘moral treatment’ held in awe by the disciples of Pinel.” 28 In establishing an outpost in asylums and claiming the mad as their clientele, these doctors made significant steps toward establishing a distinct medical specialty.

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National legislation helped to solidify the relationship between doctors and the insane. The asylum law of 1838 mandated the creation of a nationwide system of institutions dedicated to the treatment of mentally troubled citizens. “Asylums,” as they would be called, would no longer mix the insane with prisoners or indigents. The law of 1838 also specified that doctors—rather than monks or nuns—would direct asylums. Furthermore, doctors would assume legal responsibility for admissions to asylums—a duty previously bestowed on the courts. The specialized medical field that those doctors formed was called “alienism,” referring to their clientele of “mentally alienated” patients. The insane had formerly been called crazy or mad [fou], but doctors increasingly insisted that they be referred to as aliénés, a term that doctors believed had fewer negative connotations. Aliénés were said to be alienated from society, from themselves, and from reason. Alienism (also called mental medicine and other names) strengthened its place as an autonomous medical specialty through the nineteenth century. In the middle of the century, even as general medical practitioners remained somewhat unorganized outside of university faculties, alienists founded academic societies and journals. They also offered courses on mental maladies to medical students and conducted clinical teaching rounds in the wards of asylums. Toward the end of the nineteenth century, alienism was operating as a distinct medical specialty. By most accounts, neurology was born later than psychiatry.29 Although nervous disorders had long been identified in medicine, they were known primarily through observed signs and reported symptoms, not through a deep understanding of the structures and functions of the nervous system. The first steps toward that deeper understanding were taken in the early nineteenth century, when the convergence of medicine, surgery, teaching, and research in large Paris hospitals gave “birth” to clinical medicine.30 In those institutions, doctors developed the anatomo-pathological method, in which they carefully recorded clinical notes during a patient’s illness, performed an autopsy after the patient’s death, and then attempted to correlate the post-mortem findings with their recorded observations. The knowledge doctors gained allowed them to improve their interpretation of clinical signs in future patients. Through the mid-nineteenth century, advances in microscopy, along with improvements in laboratory techniques and experimental methods, enabled doctors to enhance their understanding of neuroanatomy and neurological disease.31

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By midcentury, however, there had been no real effort to consolidate knowledge about nervous disorders or to organize a separate branch of medicine around that knowledge. It was not until Charcot began his work at the Salpêtrière in the 1860s that neurology truly began to develop as a distinct medical specialty in France.32 Using an anatomo-clinical method, which privileged clinical observation above post-mortem dissections and microscopic research, Charcot precisely defined nervous illnesses that previously had been only vague diagnostic categories. He also gathered around him a coterie of students who helped extend neurological knowledge beyond the Salpêtrière. They lectured and taught abroad, and they worked with Charcot to establish medical journals and to found a neurology society. In 1882, Charcot was elected to the first-ever chair in nervous diseases in the Paris Faculty of Medicine, solidifying the place of neurology in medical education. Alienists and neurologists were already collaborating by the mid-nineteenth century, but the intensity of efforts to share information increased toward the end of the century. Many of those efforts were undertaken by alienists who hoped to attach themselves to a more prestigious and scientific medical specialty. Even as alienists were constructing their medical specialty, the practice of mental medicine was floundering. The initial optimism that had fostered the creation of asylums and the development of alienism had faded, and alienists proved unable to demonstrate the medical value of their specialty. They could not find the physical lesions or somatic processes that some initially believed were the causes of mental illnesses. Nor could they produce the cures they had promised. Consequently, their treatment of the insane did not seem to offer decided advantages over the charitable care of the Catholic Church. In the face of etiological frustrations and therapeutic impotence, the specialty deteriorated and morale among alienists plummeted. By midcentury, alienism had become the lowest-paid medical specialty with some of the fewest medical responsibilities.33 Asylums fell into disrepair, and asylums’ chronically ill residents went neglected. When censorship laws were relaxed in the 1860s, mental medicine also suffered frequent attacks from journalists, who criticized doctors’ thera­peutic failures and the arbitrary power bestowed on alienists by the law of 1838.34 Presenting scandalous cases as examples, journalists claimed that asylum doctors too frequently sequestered individuals without good cause. Legislators responded to those critiques by proposing to strip asylum doctors of their legal authority. Alienists were inappropriate judges for such legal matters, said these

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politicians, adding that they were incompetent at their own profession.35 In the 1890s, deputy Joseph Reinach stressed the immaturity of psychiatry as a science, insisting that the alienism was “still in its infancy, by its own admission.” He asserted that it was “not at all certain in its conclusions” and was often susceptible to “erroneous diagnostics.” 36 Reinach believed he was not alone in his opinion: “The negligence of asylum doctors has been denounced for fifty years by all the adversaries of the law of 1838 as one of the most frequent causes of abuse and errors.” 37 To address the problems facing their field, alienists of the late nineteenth and early twentieth centuries sought to realign their specialty with medicine proper. Forging an alliance with neurology, a neighboring field that was already immersed in microscopy and organic diseases, was an important step toward improving the status of the psychiatric specialty. The association between neurology and alienism was a natural one in several respects. Neurologists and alienists generally had similar medical training. In France, specialty training in medical education had begun in the late 1800s and training certificates were awarded for “legal medicine and psychiatry” beginning in 1903, but true certifications for major medical specialties were not created until after World War II.38 Before then, doctors had few impediments for switching from one field to another over the course of their professional careers. Throughout the nineteenth century, many of the alienists who worked in the asylums of the Seine department had studied neurology at the Salpêtrière before assuming their psychiatric posts. Up to the 1950s, professors of mental maladies at the Paris Faculty of Medicine were all trained neurologists.39 Alienism and neurology also overlapped in the study of several disorders. Doctors from both fields found that patients with neurasthenia (general nervous weakness or exhaustion), general paralysis (a disorder later linked to syphilis), and certain traumatic injuries (such as those that followed railway accidents) expressed both neurological and psychiatric symptoms. Even patients with hysteria and epilepsy (diseases claimed for neurology by Charcot) displayed psychological impairments that sometimes led to their internment in mental asylums. Neurologists and alienists began to hold joint conferences regularly in the 1890s. Meanwhile, alienists and psychologists (whose study of the mind had a more philosophical bent) contributed to meetings of the Neurology Society of Paris while neurologists contributed to meetings of psychiatric societies. Re-

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ports from these and other neurological and psychiatric meetings were published in both neurological and psychiatric journals. The term “neuropsychiatric” was used for certain maladies and as a moniker for the community of neurologists and alienists. Despite the modest level of integration that the two specialties achieved, significant differences continued to distinguish the fields at the outbreak of World War I. For example, certain diseases remained the exclusive domain of one field or the other: idiocy was form of mental alienation; Parkinson’s disease was unquestionably a neurological disorder. Moreover, doctors from each field often practiced in distinctly different milieus. Neurologists might have directed specialized wards in city hospitals or staffed outpatient clinics, whereas many alienists were relegated to isolated, suburban asylums located miles from the hospitals, clinics, and laboratories that defined the leading edge of scientific medicine. While neurology and alienism were increasingly differentiated by their focus and work setting, many of the divisions within each field were more pronounced than those that distinguished one specialty from the other. The frequently bitter debates among neurologists over the correct etiology, diagnosis, and treatment of hysteria that began before the turn of the century, for example, carved rifts in the field that wartime crises only deepened.

Organization Members of the neuropsychiatric community had to scramble to create neurological and psychiatric facilities for the military in 1914, yet there had been calls to establish such centers years earlier. Just after the turn of the century, several French doctors investigated the prevalence of mental illness among peacetime soldiers. Despite adamant denials by military authorities, doctors found that mental illness was rife among French troops.40 Around the same time, wars fought among other nations, including the Russo-Japanese War, the South African Boer war, and the American war in the Philippines, demonstrated the potential for an increased incidence of psychiatric troubles among soldiers during military conflicts.41 In 1909, at a congress for French-speaking neurologists and alienists (as psychiatrists were still called at that time), doctors presented plans for a full system of psychiatric screening and assistance for the military.42 They recommended implementing measures to reduce the acceptance of mentally debilitated men into the military, to identify mentally

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impaired men early in their service if and when they squeezed through admissions filters, and to construct a system of psychiatric centers and asylums in the field, staffed by experts, to provide better treatment to men who developed mental disturbances during their service. Military leaders were clearly overconfident in the army’s ability to screen soldiers for psychiatric illnesses successfully. Responding to the psychiatric studies by proclaiming, “If they were madmen, they would not be soldiers,” military leaders refused to adopt the recommendations of alienists.43 And by the outbreak of the First World War, there was little infrastructure in place to deal with the psychiatric cases that inevitably appeared.44 In the first months of the conflict, soldiers diagnosed with some form of mental illness were sent to military hospitals, where they were confined in old-fashioned isolation cells and forced to wait for more permanent homes to be found for them. Finally realizing the insufficiency of this system, the military called on doctors to expand psychiatric services and to militarize public insane asylums, which could house hundreds of psychologically troubled soldiers. The first autonomous military centers designated for psychiatric casualties were organized by Emmanuel Régis in Bordeaux.45 Régis had held a post at the Sainte-Anne asylum in Paris—the city’s largest psychiatric facility and the most prominent psychiatric teaching institution in the Seine department. Just prior to the war, he was the director of a health clinic in Le Bouscat and a professor of mental maladies at the Bordeaux Faculty of Medicine.46 Charged with creating psychiatric centers in three military regions, Régis made a number of recommendations for building a system in which psychiatric services would work hand-in-hand with general medical facilities. Régis acknowledged that there was some value in retaining aspects of the current scheme. Each general military hospital, he asserted, should continue to have isolation cells and observation areas for agitated, delirious, violent, and other non-transportable individuals. But those general hospitals should then be supported by a psychiatric facility at the administrative center of each military region. Within each psychiatric facility, there should be a central reception service for the examination, triage, and distribution of men to other hospitals. In addition, there should be an annex for the hospitalization and treatment of patients afflicted with psychoses (purely psychological illnesses) or psychoneuroses (illnesses with both psychological and neurological components) who did not require internment in a mental institution. If possible, that annex should be an open service in a neighboring asylum—that is, patients

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should not be legally interned, as in an insane asylum, but rather admitted as they would be to any standard medical hospital. Régis’s recommendations reflected contemporary goals of the psychiatric community. Psychiatrists (as they were increasingly called) hoped to strengthen the relationship between psychiatric services and medical hospitals. They no longer wanted to be the keepers of incurables and degenerates. Psychiatrists argued that their field was a true medical specialty that could work in conjunction with other specialties to cure patients. Psychiatric facilities, said psychiatrists, should function more like hospitals, in which treatment, rather than detention, was the primary goal. Though psychiatrists acknowledged the continued need for insane asylums to house lost causes, they envisioned the gradual eclipse of the asylum by the medicalized psychiatric hospital. While Régis was organizing his psychiatric centers for the war effort, the minister of war issued in October 1914 a circular (a type of administrative instruction for departmental prefects) mandating the establishment of neurological centers as well.47 Conceived as facilities to treat soldiers with neurological battlefield wounds ranging from head traumas to spinal injuries, these centers were to be either created as autonomous hospitals or installed in specially designated wards of large institutions. Whenever possible, they were to be placed in cities that had medical faculties to ensure that they would be directed by the top doctors. The organization of neurological centers could not occur fast enough. By late 1914, doctors at the front were reporting not only a relentless flow of soldiers with neurological injuries but also a growing number of soldiers who complained of neurological symptoms but lacked signs of organic wounds. In February 1915, the Neurology Society of Paris responded to the influx of these mysterious neurological cases by refocusing the organizational plan for neurological centers to address those disorders specifically. The society followed Babinski’s understanding of the crisis. According to Babinski, the vast majority of soldiers with functional disorders were pithiatics. Either consciously or unconsciously, they developed neurological symptoms to avoid duty. Reflex tests (sometimes performed after the patient was sedated with chloroform) and other neurological measures proved that there was nothing physically wrong with them. They could—and should—be treated only with stern persuasion. Using Babinski’s conception of pithiatism as its foundation, the Neurology Society sent a list of organizational recommendations to the minister of war.48

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The society advocated establishing specialized neurological services, staffed by experts, where all soldiers suffering from nervous troubles (either organic or functional) could be treated as early as possible after the appearance of symptoms. Those centers would be supported by separate medical-military centers, where suspected simulators and soldiers with persisting symptoms could be watched and disciplined. Though the disciplinary centers were put on hold, the army established neurological centers in the first part of 1915.49 By the spring, however, neurologists began to recommend additional neurological stations, located closer to the front. Gustave Roussy argued that there would a great benefit to examining and treating patients even earlier in the course of their illnesses.50 Pithiatic soldiers should be identified and treated before they could reach the comfort and security of hospitals in the interior. Not only would such transfers allow suggestions to take deeper root, Roussy contended, but they also would enable suggestions to pass from pithiatic men to physically injured men, thereby delaying the recovery of those who were truly wounded. Roussy proposed creating a forward-positioned neurological center for each army, which would be staffed by specialists whose primary goals would be to diagnose patients correctly, treat on the spot patients with mild neuropsychiatric conditions, and detect simulators. In 1916, Roussy reported that his recommendations had been accepted and had already produced impressive results. As Roussy and his colleague Jules Boisseau noted from their neuro­ psychiatric center, “the results obtained have surpassed our expectation and merit, we believe, the attention of the authorities.” 51 Like the proposals of Régis, the recommendations of Roussy and other neurologists reflected particular professional goals. Neurologists hoped to show that they were experts at not only treating true, confirmed organic diseases and injuries but also at differentiating true neurological disorders from malingering. By conquering the epidemic of functional illnesses, neurologists would demonstrate the advanced state of their field, the important contributions they could make to medicine, and the key roles they could play in the war effort. According to Roussy, the challenges presented by functional illnesses renewed the activity of neurologists and placed “this science at the foreground of medical questions raised by modern warfare.” 52 While psychiatric and neurological services were separate in some regions, the need to conserve space, materials, and personnel led to the creation of combined neuropsychiatric centers in other regions.53 Maurice Dide,

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who directed a neuropsychiatric center of the Eighth Army, contended that it made perfect sense to bring neurological and psychiatric services together. Functional neurological cases contained such a preponderant psychological element that it was “illogical to separate the two sister branches.” 54 Roussy and Boisseau agreed. They believed that in combined centers, cases that straddled the line between neurological and psychiatric disorders—such as the functional cases that were becoming legion—would not fall between the cracks.55 Roussy and Boisseau provided a rare glimpse into the organization and functioning of a wartime neuropsychiatric center in an article they published in Paris médical in 1916. The center, which was located in a former house of detention that had been converted to a military hospital, received all the soldiers from that region’s army with neurological problems, as well as those with mental troubles. According to the doctors, however, soldiers with functional troubles were in the majority. As it was with the majority of centers, the operation of Roussy and Boisseau’s neuropsychiatric station reflected the ideological positions of its directors while also supporting overarching professional goals. The center had been established close to the front so that doctors could diagnose and treat men soon after the appearance of symptoms. Roussy insisted that soldiers with curable neurological disorders and mild mental illnesses be treated before being evacuated to comfortable hospitals in the interior, where friends, relatives, and even inadequately trained practitioners might inadvertently prolong their illnesses. Patients with functional problems—especially exaggerators—needed to realize that there was no hope of being sent home. Roussy and Boisseau’s center was organized to facilitate isolation—a key component of the doctors’ treatment regime. As soldiers with functional illnesses arrived, doctors isolated them from one another to avoid contagion of their imagined symptoms. Like other neurologists, Roussy believed that a patient might incorporate the observable disturbances of another soldier into his own illness, complicating treatment and delaying recovery. Once examined, patients with organic nervous disorders or functional maladies were placed in a pavilion that was divided by partitions, creating numerous small rooms with only two beds each. Agitated mental patients and soldiers who needed to be detained until the war council could send medical experts were isolated in individual rooms. By contrast, patients requiring surgery or the repeated dressing of physical wounds were placed in one of two common wards with fifteen beds each.

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The doctors insisted on strictly controlling the therapeutic environment. Though the center was not meant to be one of the disciplinary centers proposed by neurologists, Roussy nevertheless created an atmosphere of military discipline, in which authoritative doctors exuded an air of confidence and projected the inevitability of cures. According to Roussy, the results of a patient’s treatment depended heavily on the perceived power of the doctor: “It is, indeed, common to see patients who carry their neuropathy, their tremor, their spasmodic tic, or nervous crises from hospital to hospital, and end by becoming ‘cured’ [only] when they have at last found ‘their master.’” 56 Roussy believed that, once cured, soldiers could positively influence their comrades still in treatment. Cured men promoted a return to health among all patients by demonstrating the efficacy of the therapeutic regime. To encourage this sort of “benign contagion,” doctors placed convalescing patients, including those who had suffered functional disorders, together in tents located in the building’s courtyard. Of course, not all the soldiers processed through the center could be cured. Soldiers requiring more extensive treatment for neurological injuries were sent back to specialized centers in the interior. Soldiers with persisting neuropsychiatric disorders or severe psychiatric illnesses were sent either to Val-de-Grâce military hospital in Paris by hospital train (if they were easily transportable) or to a nearby asylum by car. Reports from other neuropsychiatric centers noted that soldiers sent by train to the interior were transported in locked compartments with grilled windows.57 These soldiers were accompanied by nurses who carried their patients’ dossiers in sealed envelopes. The practice of securing medical records to prevent neuropsychiatric patients from gaining access to medical opinions was not uncommon during the war, and it was consistent with many doctors’ attitudes toward men with functional disorders.58 According to doctors, these soldiers were quite possibly faking—either consciously or unconsciously. Reading their doctors’ notes might help them perpetuate their lies. Yet the fact that the envelopes accompanying asylum-bound men were to be sealed seems odd. These were the doomed men whose conditions were so severe that they were to be locked away in mental institutions. What would it matter if they caught a glance of their doctors’ scribblings? The mandate to secure the records of even these men provides an important clue about the doctor-patient relationship during the war: many doctors demanded absolute control over their patients. Like the hospital doctors a century earlier, whose

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use of Latin while conducting clinical rounds prevented their undereducated subjects from comprehending them, wartime doctors asserted their power over soldier-patients by denying them access to information even about their own conditions.

Treatment In the case of pithiatics, Babinski’s treatment recommendations were best aligned with the military’s goals of returning men to battle. If neurologists suspected pithiatism in the specialized neurological centers close to the front, those experts—in the atmosphere of confidence and authority that they created—were to act quickly, providing a brusque course of counter-suggestion, or persuasion.59 In cases where patients were unable to benefit from this “rational psychotherapy” (a term sometimes used for counter-suggestion), Babinski endorsed the use of “material” methods, such as electrical stimulation.60 The directors of many neuropsychiatric centers saw the utility of Babinski’s method, but reports issued from the neuropsychiatric centers during the war indicate the persistence of a variety of subtly different therapeutic approaches to war-related neuropsychiatric syndromes.61 Treatments given at each center reflected the director’s own professional focus and his beliefs about the causes and classification of each disorder. For example, Paul Sollier, a neurologist and former student of Charcot who manned a neurological center in Lyon, strongly rejected Babinski’s persuasive therapy as a means of treating functional disorders.62 Sollier, who had written tomes on the causes and proper treatment of hysteria nearly two decades before the war, agreed that “suggestion” could be harmful to soldiers, but he included “persuasion” among potentially malevolent influences as well. Sollier believed that hysteria was, at its root, a physiological disturbance of the brain. A functional disturbance in a limb, for example, was caused by a numbing, or a “sleep,” of a corresponding area of the brain. Consequently, in treating hysteria, Sollier recommended a variety of treatments meant to awaken the brain from its somnolence. During the war, Sollier endorsed above all physical treatments, including hydrotherapy and mecanotherapy (hands-on manipulation), to treat the frequently localized disturbances of patients’ limbs. Still, he also recognized the utility of isolating patients, establishing an authoritative attitude toward them, and guiding them back to proper functioning through close supervision, even if he insisted that this form of traitement morale bore no relation to Babinski’s treatment.

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Georges Dumas, a psychiatrist and later professor of psychology who finished the war as the director of a neuropsychiatric center, generally used a version of persuasion in combination with short electrical shocks. He reported that this technique was particularly effective for the treatment of mutes. According to Dumas, “almost all spoke from the first session.” At first, he reported, the patient responded to the electrical shock with an audible cry of pain and surprise. From that utterance, the patient realized that he was able to emit sound. The doctor then encouraged him to pronounce all of the vowels: “Say: E, you can do it; come on, hurry.” 63 Finally, the doctor instructed the patient to repeat set phrases: “I am going to get better. . . . I am no longer mute.” 64 Although Dumas seemed to favor Babinski’s recommended techniques, he admitted that some doctors had achieved success by offering incentives in combination with forceful suggestions. At one hospital, doctors told patients to say “I want a glass of Bordeaux.” Doctors believed that a mute patient would have a double interest in uttering that phrase, since, according to Dumas, “one would not refuse to him, after his cure, the glass in question.” 65 At Gustave Roussy’s centers, doctors employed a multipronged approach to functional patients.66 After patients were isolated from one another, the doctor began what Roussy called “rational and persuasive” psychotherapy.67 During the first meeting with a patient, the doctor explained the causes of the disorder and reassured the patient—quietly, kindly, but firmly—that it would be cured rapidly. As the first session of therapy ended, the doctor made the patient take an oath in which he promised to get well. The patient was then isolated again. He was kept in bed and placed on a strict milk diet, which was intended to calm him and remedy any digestive problems caused by poor diet or alcoholic excesses. For Roussy, isolation was a valuable aid to psychotherapy: leaving the patient alone with his thoughts encouraged him to contemplate his disorder and his oath to contribute to his cure. The doctor reinforced these advantageous ruminations through short talks with the patient during daily rounds. The doctor then began electrical therapy to demonstrate to the patient that his anesthetized or paralyzed body parts could in fact function normally. During the first session, the patient was made to lie absolutely naked on a bed, no doubt to enhance his vulnerability before the imposing physician. Working alone or with minimal staff support, the doctor used electrodes hooked up to batteries to apply increasingly intense shocks to the patient. The electrical

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shocks did nothing to actually treat the patient’s nerves; they served only to prove to the patient that he lacked true, organic injuries. Some patients were spared electricity but instead submitted to intense hydrotherapy. By dousing patients with cold showers or striking them with jets of water, doctors hoped to shock their charges into a cathartic crisis. According to Roussy, other treatment methods, including the use of slightly painful subcutaneous injections of ether, might be used in stations closer to the front, where electricity or hydrotherapy could not be applied. Once cured by these methods, typically in just two or three sessions, patients began a course of physical and psychic reeducation. Doctors used physiotherapy to help reestablish lost functions. Psychotherapy, and if necessary, electrical treatment, supplemented the physical reeducation. Through this process, which took two to three weeks, the patient was under constant surveillance and repeatedly reassured of his inevitable recovery. Though aspects of Roussy’s treatment of functional problems involved the body, its focus was the mind. Neurologists needed to convince patients that they lacked any true injuries. According to Roussy, “The cure of a psycho­neuropath really consists of a mental contest, resulting in the victory of the physician. This . . . is the secret of psychotherapy.” 68 Because functional disorders were supposed to be easily curable, and because neurologists were supposed to be expert at persuasive therapy, doctors often portrayed the process of persuasion as a short, simple procedure. André Léri, a neurologist who directed the neuropsychiatric center of the Second Army, described the cure of a twenty-one-year-old corporal with functional leg paralysis in a cursory fashion: “A single session of suggestion, aided by a faradic [electrical shock] apparatus, modified the [functional] phenomena in a complete manner.” 69 André Gilles, an intern in the asylums of the Seine, reported in similarly brief terms the treatment of a soldier who had become mute following a nearby explosion: “I immediately revealed to him the purely psychopathic nature of his state . . . ; the same afternoon, by simple persuasion, he was cured, three days after the initial shock.” 70 In reality, however, not all cases were so easily cured. Patients who did not respond to simple persuasion were sent to doctors who used high doses of electricity to jolt them out of their state. Like Babinski, Clovis Vincent, who directed the center in Tours after 1915, advocated the quick intervention of a powerful doctor to cure hysteria. But even more than Babinski, Vincent strongly supported a system of electric shocks, or torpillage as it came to be

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called (literally, “torpedoing”), to weaken a patient’s pithiatic resistance to persuasion. The electrical shock was followed by either direct reeducation (in which the patient was compelled to make a movement of which he claimed to be incapable) or indirect reeducation (in which he was led to the goal mechanically). An intensive exercise program and retraining followed. As Marc Roudebush has shown, Vincent’s center became a sort of clearinghouse for problem cases until a rebellious patient brought these practices to public scrutiny.71 Baptiste Deschamps, a soldier who was sent to Vincent for a functional back problem, punched Vincent out of fear of electrocution when the doctor came toward him with two electrodes. Deschamps was tried before a military tribunal for his action and found guilty of assault, but the public outcry on his behalf—voiced in the popular press—forced military administrators to give him a lenient, suspended sentence. Roudebush claims that Vincent’s brutal methods consequently fell out of favor among military doctors, though various forms of persuasion and electrical therapy certainly continued to be used through the end of the war. Psychiatrists, whose patients suffered from more typical psychological disorders (such as depression, delirium, and alcoholism), often employed the full range of therapies already in use in asylums and private clinics. The psychiatrist Henri Damaye, for example, began by cleansing both the outside and the inside of his psychiatric patients.72 Soldiers were first subjected to baths—one temperature was specified for calm men, another for excited men. They were then purged with calomel. They were initially put on a milk regime, then a lacto-vegetarian diet. Stimulants were administered to help digestion and to revive the body. Other injections could follow, depending on a patient’s diagnosis. Melancholics were given additional stimulants, while anxious men were administered sedatives or opiates. Once the patient’s body was cleansed, he was stabilized, and any acute phases of the disorder had passed, the doctor would begin to “regenerate the organism,” as Régis had phrased it years before the war, in reference to the treatment of mental confusion.73 Even in this second stage, however, doctors would address both the body and mind of a patient. Physical regeneration might involve continued hydrotherapy plus electrotherapy, frictions, massages, physical exercise, and a variety of injections. Mental regeneration might be accomplished through an abbreviated version of psychotherapy. The doctor would talk to the patient, firmly redirecting the patient’s ideas, with the goal of providing some “reeducation,” or readaptation to the world.

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Even if some doctors chose to apply the more in-depth sort of psychotherapy practiced by Dejerine on R., no French doctors practiced psychoanalysis during the war. In 1914, Freud’s work had only recently been introduced to the French public, and it was poorly received. Angelo Hesnard and Emmanuel Régis, who published the first full-length French work on Freudian theory in 1914, stated in the preface that their book was meant as a critical examination of psychoanalysis, not a recapitulation of Freudian dogma.74 Outlining what would become a frequent critique of Freud, Hesnard and Régis portrayed psychoanalysis—the “German theory,” as they called it—as more of a religion, philosophy, or form of mysticism than science. Freudian doctrine was incomplete, its ideas still in the process of elaboration. It also focused too heavily on sex. Moreover, it was unoriginal: the concept of repression had already been noted by French authors, as had the idea of psychic analysis (a practice explored previously by Janet). Still, the authors generously conceded, psychoanalytic theory might have some redeeming qualities. Even if French doctors could read past this highly critical introduction of Freudian ideas, they would have found other stumbling blocks to adopting psychoanalysis for the war effort. First, there were no formally trained psychoanalysts in France, and there wouldn’t be any until 1921. Second, Freud’s interpretation of war neuroses appeared only at the tail end of the war, and then only in German.75 While the British had several trained psychoanalysts and were sufficiently immersed in Freudian theory to apply Freudian ideas to shell-shocked soldiers, the French would have been unable to create those psychoanalytic conceptions on their own. The interpretation of war neuroses that Freud did ultimately present would not have found many supporters among French neurologists and psychiatrists. Freud maintained that the roots of war neuroses were found in unconscious psychological conflicts.76 The development of a functional illness was the result of the ego protecting the individual from both the physical danger of war and the danger of psychic disintegration, which could result from the battle between the peaceful ego and its warlike alter ego. French doctors would have objected to Freud’s assessment, not only because it was imbued in a language and theory that they disliked, but also because it removed much of the blame of functional illnesses from soldiers. While French doctors accused soldiers of malingering, Freud portrayed most neurotic men as merely succumbing to the irresistible force of their unconscious drives. Freud’s etiological assessment of war neuroses and his penchant for using

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psychoanalysis to treat neuroses also led him to oppose the use of electrical shocks in treating neurotic soldiers—a treatment, as we have seen, favored by many French doctors. Freud further opposed the forced isolation, mock surgeries, and repeated baths used by doctors in Germany and Austria, as well as France. According to Freud, the goals of these treatments—which included creating feeling of helplessness in soldiers and shaking them out of their pathological intentions—were misguided.77 Doctors employing electrical shocks wrongly considered soldiers to be fakers, he asserted, whereas in fact most soldiers were only unconsciously malingering. Because the functional illnesses that soldiers displayed were due to deeper conflicts, electrical shocks and similar treatments were doomed to failure. While shocks did deprive soldiers of an important advantage of being ill—the removal from a dangerous or painful situation—they did not cure the underlying neuroses. Freud admitted that the practice of psychoanalysis in times of war would have been difficult to apply; nevertheless, he insisted that the application of psychoanalytic principles would have been more successful than electrical therapy.78 While the French psychiatric community was unwilling or unable to use psychoanalysis for soldiers with war-induced disorders, they were not averse to trying new modes of institutional organization. For example, as Régis recommended, some psychiatrists established open psychiatric services, where mildly troubled soldiers could be treated without the threat of internment in a locked mental asylum. Pierre Kahn directed an open psychiatric service during the war, and a Dr. Charron created an open sanatorium with permission from the military. Still, the birth of the psychiatric hospital would have to wait until after the war, when psychiatric reformers could successfully argue that the psychological trauma of war had necessitated a drastic change in psychiatric care.

Accounting From their neurological and psychiatric centers, wartime doctors frequently shared reports on the incidence of functional disorders and other illnesses. Were functional disorders truly epidemic? Doctors could not seem to agree. While some doctors presented statistics that suggested a fast-spreading plague among the troops, others exercised caution in reaching any conclusions. Several factors made the collection of comprehensive and accurate statistics next to impossible during the war. First, diagnostic categories varied widely

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from one center to the next. Doctors used terms that supported their own etiological beliefs and professional expertise. What was labeled “pithiatism” in one center might have been called “commotion” at another. To have collected statistics of all pithiatics, then, would have failed to capture the incidence of all functional illnesses. Second, patients were often transferred to multiple centers before being discharged or sent back to battle. In theory, medical dossiers were to accompany patients over the course of their journeys, but in practice, many patients arrived at new centers with very little or none of their medical information. Thus it was difficult to keep track of which soldiers had already been counted for statistical purposes and for what category of illness. Third, recidivism, which was no doubt rampant, especially among suspected malingers, was poorly monitored by many doctors. Confounding recidivists with first-time patients skewed statistics significantly. Moreover, doctors colored the interpretation of statistics in ways to support their own conclusions about the causes of disorders and to underscore their own effectiveness in treating them. Paul Sollier’s statistical report on cases of war-related neuroses, presented to the French Academy of Medicine in June 1915, downplayed their prevalence among the troops: “Some observers, basing personal statistics . . . on too few cases, have claimed that the number of cases of neurosis in the course of the war is presently enormous, that it is rising, and that there is reason to take energetic measures to minimize this damage. Yet the examination of the collection of statistics from neurological centers shows that it is far from being so.” 79 According to Sollier, these cases were fewer by far than cases of true nervous system injuries. Sollier showed that of the 2,435 patients seen at French neurological centers by June 1915, only 395 (16.2 percent) were diagnosed with neuroses (the term he preferred, which would have included what other doctors called hysteria, pithiatism, and functional disorders). He noted that if one were to remove recidivists from that figure, the total would probably be reduced to 250 cases. Sollier suggested that even if neurologists had failed to account for three times that number of cases, the resulting number of cases (1,000) would still be relatively small and “almost negligible” in comparison to the numbers of other nervous system injuries.80 Sollier maintained that it was unlikely that the number of cases of war neuroses would increase. First, he contended, neurologists had probably seen any and all patients who might develop these neuroses. He thus implied that neuroses—whatever their causes—were not disorders that could afflict the

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entire population. As he argued in a postwar work, they were found among men who predisposed to them.81 In his report to the Academy of Medicine, Sollier also reasoned that the neurological centers created for the war effort kept the incidence of neuroses in check. That statement reflects not only his deep confidence in his methods for treating neuroses but also a strong desire to present the neurological community in a positive light before the Academy of Medicine. Although Sollier insisted that the outbreak of neurosis was under control, many of his colleagues had a very different impression. Maxime Laignel­Lavastine, who at the time was directing the neurological center at Tours, wrote in December 1915 that the frequency of hysteria with somatic manifestations was “enormous.” 82 Henri Claude, who directed the neurological center in Bourges, wrote that “the number of functional motor or sensory troubles to which one cannot attach an evident organic cause among wounded soldiers is considerable.” 83 Similarly, Pierre Marie, who directed a militarized neurology service at the Salpêtrière in Paris, wrote that “a very large number of subjects directed to our service present no objective, clinical sign of an organic lesion of the nervous system and nevertheless one finds in them paralytic or spasmodic troubles, sensory troubles, [etc.].” 84 André Gilles claimed that nearly a quarter of the patients his service received from neuropsychiatric centers were plagued by functional troubles.85 At the end of 1915, Sollier admitted that functional disorders, which often appeared in forms similar to those identified by Charcot, were “extremely frequent.” 86 But the following year he claimed that functional cases among soldiers were declining since their first appearance in 1914.87 At his own neurology center in Lyon, Sollier had observed 259 cases during the five months of war in 1914, 271 cases in all of 1915, and a mere 31 cases in the first nine months of 1916.88 As the war dragged on, however, reports of the frequent incidence of functional disorders or hysteria continued to be filed from other neuropsychia­ tric services. Pierre Marie reported that his neurology ward at the Salpêtrière and other centers had seen a “renewed outbreak” of hysterical troubles in 1917—possibly the result of renewed offensives launched that spring by the High Command.89 Maxime Laignel-Lavastine also reported seeing a large number of cases, especially among soldiers at the Gare de l’Est train station in Paris, which men on leave used when returning to the front.90 André Léri wrote that functional troubles counted for close to 50 percent of the approxi-

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mately 1,800 soldiers that he had treated in his neuropsychiatric center in Rennes over the course of eight months.91 By contrast, doctors from the psychiatric services within neuropsychiatric centers and from independent psychiatric facilities elsewhere in the country reported relatively few cases of war hysteria. Roger Dupouy, a psychiatrist who worked at the neuropsychiatric center of the Fifth Army, reported only 4 cases of hysteria among the first 100 patients (4 percent) that he saw in 1915.92 Henri Damaye, the psychiatrist who directed the neuropsychiatric center of the Fifth and Sixth Armies, reported 8 cases of hystero-epilepsy among 638 patients (1.2 percent) seen between May and December 1916.93 He noted that he rarely encountered cases of pure hysteria. Ernest Montembault, then a medical student working at the asylum of Navarre, reported only 2 cases (1.6 percent) of hystero-traumatism out of 122 mentally ill soldiers admitted to the asylum between August 1914 and October 1916.94 René Charpentier, who directed a wartime psychiatric center, recorded 15 cases of what he called pure pithiatism among 195 total psychiatric cases (7.6 percent) for the months of April through June 1917.95 Instead of hysteria, doctors from psychiatric services saw a preponderance of depression, anxiety, and alcoholism.96 At Dupouy’s center, 18 percent of soldiers were diagnosed with melancholic depression or hypochondria; 10 percent suffered from alcoholism. Damaye did not report alcohol-related cases, but he did note that 11 percent of soldiers were afflicted with depressive melancholy, anxiety, or delirium with ideas of persecution. An additional 8 percent suffered from other types of melancholy, including melancholy with depression and anxiety, or melancholy associated with a neurasthenic state, among others. In Navarre, Montembault diagnosed 35 percent of his patients with periodic exhaustion or weakness in a melancholic phase.97 At Charpentier’s center, 15 percent of soldiers had melancholy—twice the percentage of soldiers with pithiatism—and nearly 7 percent were diagnosed with some form of alcoholism. Jean Lépine, director of the psychiatric center at Lyon, reported that between 30 and 35 percent of the 5,000 patients examined at his center were diagnosed with alcoholism.98 Why was there such a discrepancy between the numbers of functional disorders reported by various neuropsychiatric centers? There are several possible explanations. First, as mentioned earlier, diagnostic categories varied widely from one center to the next. Some centers recorded fewer cases of hysteria and other functional disorders simply because their doctors chose to use al-

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ternate diagnostic terms. Second, soldiers were often segregated according to their injuries and complaints before reaching these centers. Men exhibiting bizarre behaviors that were thought to be related to mental problems were sent to doctors specializing in psychiatry. Those complaining of neurological symptoms—such as the anesthesias, paralyses, spasms, and contortions that defined war hysteria—were sent to neurologists, who had the task of differentiating genuine physical injuries from malingering. Consequently, neurologists were more likely to see functional disorders than their psychiatric counterparts. The psychiatrists who did encounter functional disorders did so only because neurological and psychiatric services often worked hand in hand within neuropsychiatric centers and because hysterical symptoms sometimes appeared similar to the symptoms of psychiatric diseases. The impression of some doctors that hysteria was widespread among soldiers was also due to their preconceptions about the general prevalence of the disease. In the twenty years since Charcot’s death in 1893, the number of cases of hysteria in French hospitals, outpatient services, and asylums appeared to have diminished. Babinski did not succeed in replacing hysteria with pithiatism, but he accurately described the “dismemberment” of hysteria that had taken place in those decades: doctors had attributed many of hysteria’s symptoms to other disorders. The wartime resurgence of classic hyster­ical symptoms—and the inability of doctors to pin those symptoms on any other disorders—was thus surprising to neurologists and psychiatrists, many of whom believed that the diagnostic category had been dismantled and the disorder effectively eliminated. As Pierre Marie reported in 1917, doctors were seeing a range of hysterical manifestations “that one believed had disappeared.” 99 Some doctors overemphasized the prevalence of hysteria simply because it was much more prevalent than they expected. Many doctors were particularly surprised and troubled by hysteria’s appearance in soldiers. Combatants—warriors—were supposed to be the opposite of the weak, generally female, type that many doctors still believed was prone to the affliction.100 Even if the number of hysterical cases had been relatively slight compared to other neurological or psychiatric disorders, its very existence among French soldiers caused some doctors to develop the impression of an epidemic. Neurologists, whose job it was to identify and cure hysteria, had important secondary motives for over-reporting cases of war hysteria. First, those cases provided fresh samples for debates about the disease that were well un-

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derway before the outbreak of the war. In professional meetings and in the pages of journals, neurologists frequently used wartime cases to support their theoretical positions on hysteria’s etiology and proper treatment. Second, in emphasizing the prevalence of hysterical cases, neurologists hoped to promote their own professional capabilities. By depicting the outbreak of hysteria among troops as a serious puzzle that only they could solve, neurologists portrayed themselves as heroic practitioners of a robust medical specialty.101 Yet while many neurologists were accurate in their accounting of hysterical cases, some doubtless were overly zealous in diagnosing the disorder. As with over­reporting, over-diagnosing ultimately helped to highlight neurologists’ skills as diagnosticians and therapists. Neurologists were quick to diagnosis soldiers with hysteria or pithiatism because they hoped to use the particular connotations that accompanied those diagnoses as part of the cure. Many French doctors believed that mute, trembling, paralyzed men who lacked organic injuries were weak-willed shirkers. Unlike the British term “shell shock,” which protected the dignity of traumatized soldiers by suggesting a relationship between their symptoms and the physical trauma that followed shell explosions, the terms “hysteria” and “pithiatism” underscored the inherent weakness of patients. Hysterics and pithiatics were suggestible wimps who could be cured by simple persuasion. Hysteria, moreover, connoted femininity. Although Charcot had dispelled the myth that hysterical symptoms were rooted in female anatomy, members of the medical community—and the public—continued to associate hysteria with women. For a doctor to diagnose a soldier with hysteria, then, was to challenge his masculinity.102 And that was part of the plan. Babinski and others believed that hysterical soldiers should be given no incentives to remain hysterical. Many French doctors humiliated traumatized soldiers by calling them hysterical and then threatening them with physical pain or disciplinary measures. Doctors believed that given those options, few hysterical men would choose to continue to feign illness. The threat posed to soldiers’ masculinity was particularly poignant in early twentieth-century France. As the historian Robert Nye has shown, France had been suffering a crisis of masculinity for some time.103 The decline in population that had begun around the middle of the nineteenth century had called into question the virility of French men, creating angst in society at large and generating hostility toward behaviors that were considered less than masculine. Men had attempted to restore their honor and masculinity by adopting

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old male codes of honor and military virtues such as personal courage and heroism, but the war laid courage, heroism, honor, and masculinity to waste. Doctors contributed to that destructive process. Labeling traumatized soldiers as hysterical for therapeutic purposes was a direct assault on the masculinity that nearly all French men prized. If French doctors had multiple motives for over-diagnosing or over-re­porting functional disorders, they had at least one compelling motive to downplay that prevalence and to restrict the use of terms like hysteria and pithiatism in diagnostics. To report that the French army was riddled with imagined illnesses was to admit that it was weak. Though doctors were all too willing to label soldiers as weak as part of their medical treatment, French doctors were, after all, French. They (as well as politicians and military leaders) were very concerned about fostering an image of a weak-willed fighting force. French doctors might have had less to worry about if their medical journals had been censored as extensively as newspapers during the war. In 1915, the minister of public instruction warned the leading psychiatric society of the possible dangers to national security of publishing reports and articles in medical journals without submitting them first to censors. Still, as the historian Françoise Jacob has found, censorship remained relatively light. For example, as Jacob found, sections of a 1916 article on imbeciles in the army, published in the leading psychiatric journal, were edited to remove sections on desertions, rebellions, and socialist fraternization. In addition, the names of the armies that were supported by doctors (such as the Fifth Army or the Ninth Army) were sometimes, though not always, censored. But, as Jacob suggests, for the most part, the army saw the value in allowing doctors some freedom in their work. Consequently, censorship was largely left to the doctors themselves. And they struggled to reconcile the pursuit of science with the aims of war.104 If French doctors were concerned about portraying the army as weakwilled, they did not have to worry that those portrayals would reach much of the French public. Relatively few mentions of war-induced neuropsychiatric illnesses made it to the pages of French daily newspapers. Le Figaro, for example, which provided weekly coverage of the meetings of the Academy of Medicine, gave only a few scant lines to Sollier’s report from December 1914 on neuroses. The reporter reiterated Sollier’s observation that neuroses were “so numerous since the debut of the war that special services were created to treat them.” 105 But in June 1915, when Sollier presented his carefully interpreted statistical report on war neuroses to the Academy of Medicine,

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Le Figaro allotted it only a single sentence: “Mr. Raphaël Blanchard, in the name of Mr. Sollier, communicated a statistic from the cases of neuroses due to the war.” 106 Newspapers did not censor terms such as “hysteria” or “pithiatism,” both of which appeared throughout the war in reports from the Academy of Medicine. But French newspapers did not describe an epidemic of those illnesses at the front.107 Apparently to reassure themselves of the universal nature of neuropsychiatric disorders, several members of the French medical community presented studies of neuropsychiatric illness in other armies as well as their own. Writing about psychiatric problems, Paul Chavigny, a junior professor at the Paris military hospital Val-de-Grâce and director of a psychiatric service for the Third Army during the war, expressed in print the relief that others no doubt felt when they discovered that the enemy suffered from psychiatric and neuropsychiatric disorders as well. As he wrote, “The Germans would not hesitate to [implicate] the state of our race’s degeneracy [in our high rate of psychiatric disorders]. Very fortunately, some recent publications have indicated to us that German journals were expressing dismay at the very numerous cases of mental alienation in the Austro-German armies.” 108 Writing after the war, André Gilles displayed a similar sentiment. He noted that psychoneuroses were rampant among German troops. In fact, wrote Gilles, the “proportion of incurables [among the Germans] . . . leads us to think that the number of cases of psychoneurosis was more considerable in our enemies than in [our own troops].” 109 George Dumas and Henri Aimé conducted a comprehensive review of the German-language medical literature after the war, and they published a fulllength study on the neuropsychiatric disorders found among Austrian and German troops.110 According to Dumas and Aimé, some German writers had claimed that German soldiers were better able to resist mental illness than their wartime “Latin” opponents. The Latins were predisposed toward mental illness, said one German writer; superior German culture prevented mental illness among German soldiers, said another. Nevertheless, Dumas and Aimé somewhat triumphantly found a preponderance of German doctors who admitted that from the moment of mobilization, there was a marked increase in neuropsychiatric maladies among Austrian and German troops. Indeed, the French army was in no way uniquely susceptible to neuropsychiatric disorders. British, American, Russian, Austrian, and German armies also felt the massive burden of these illnesses, many of which appeared to

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be related to the horrors of war. How prevalent were war-induced disorders among other nations? Some British doctors claimed to see an epidemic of functional disorders during the war. Yet, as the American doctor Thomas Salmon wrote in 1917, the prevalence of shell shock, mental diseases, and war neuroses in the British army was difficult to tabulate because of the wide-ranging nomenclature employed by British doctors.111 Though the precise number of British men who suffered from neuropsychiatric disorders caused by the war remains unknown, more than 150,000 men had claimed disability pensions for psychiatric disorders and other, possibly war-induced syndromes by 1939.112 In the United States, one American researcher during the 1940s claimed that 58 percent of all patients in U.S. veterans’ hospitals (68,000 men) were neuropsychiatric casualties of World War I.113 The precise number of German soldiers who suffered from war-induced neuropsychiatric disorders is similarly difficult to establish, in part because of diagnostic inconsistencies, especially early in the war. The German psychiatrist Robert Gaupp estimated that at least 613,000 soldiers suffered from war neuroses—by that estimation, more men suffered from war neuroses than any other type of illness.114 Whether or not that number is accurate, certainly the Germans perceived an epidemic, as the historians José Brunner and Paul Lerner have shown. To help curb the epidemic, many German doctors ultimately settled on the term “hysteria” for functional disorders.115 As in France, the term was used in part because of its “negative stigma and enduring feminine associations.” 116 German doctors believed that many hysterical men were faking, not just to avoid duty but also to collect pensions (which, more so than in France, was a possibility for traumatized men). Recalling the epidemic of pension neuroses that appeared in the late 1800s following the passing of accident insurance laws, doctors saw the masses of hysterical German soldiers as weak-willed shirkers who threatened to infect the morale of society and drain the German government of enormous amounts of money through pension payments.

Labeling A soldier named Louis was found wandering a street in a stupor in January 1915.117 When questioned, he was “frozen” and inert, and he stayed that way for a month. Then Louis had a nightmare in which he relived a poignant scene from the trenches. In the dream, as it had been in real life, Louis was “com-

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motioned” by an explosion. He reported, “I can see only cadavers around me; they are everywhere.” 118 The dream seems to have served a cathartic purpose: Louis’s confused state disappeared the next day. He was capable of recounting the events that preceded the blast and his subsequent commotion. A few days later, he was considered cured and was doubtless returned to duty. What illness did Louis have? Was he suffering from “commotional syndrome,” “delirium,” or “amnesia”? His doctors diagnosed him with “mental confusion following commotion,” but his symptoms might easily have earned him a wide variety of other labels.119 The selection of diagnostic labels generated serious debate within the neuropsychiatric community during the war. Since diagnostic choices often reflected etiological explanations, those debates became folded into the study of the causes of wartime illnesses. Using the category of “commotional syndrome” rather than “pithiatism,” for example, clearly demonstrated a particular etiological position. At the same time, debates over diagnostic categories raised a related scientific question: could the war produce new forms of illness? Some doctors argued that the horrific conditions of modern warfare— including the continual explosions of mines, bombs, and heavy artillery fire— produced new varieties of illness, previously unknown in the classification of disease. Others insisted that the war did little to alter existing categories. Attempts to find the right diagnostic labels for soldiers were not solely academic exercises. Those decisions had important implications for soldiers. First, the labels that doctors attached to soldiers were guides to treatment. A soldier diagnosed with cerebral commotion due to a nearby shell blast underwent a very different type of treatment than a soldier labeled as pithiatic. Someone knocked into a stupor by an explosion was treated differently than an “imbecile.” Second, diagnostic labels were guides to prognostics. A soldier diagnosed with acute mental confusion was expected to recover in short order. A soldier with chronic delirium—who, in the near term, might display similar symptoms—was not expected to improve. Consequently, the temporarily confused soldier would have been kept in a military psychiatric center, while the chronically delirious patient would have been sent toward the interior, where he might have been interned in an insane asylum. Finally, diagnostic labels were guides to discharge and pension decisions. The potential for cure determined whether a soldier would leave military service or return to the front. Combined with an assessment of whether his illness was attributable to mili-

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tary service, a soldier’s diagnosis and prognosis determined how much monetary compensation he could receive for his service. The diagnostic inconsistencies among French doctors were partly attributable to the lack of a uniform, universally accepted system of disease classification.120 In the first part of the twentieth century, there was no standard text to which neurologists and psychiatrists could refer for diagnostic criteria. Certain works had become commonly used textbooks for students, but in practice, doctors often diverged from the categories found in those books. Without a standard classification system, diagnoses were colored by doctors’ areas of professional expertise as well as by their theoretical beliefs. A soldier who cried while trembling and exhibiting muscle weakness, for example, might have received a diagnosis of hysteria from a neurologist, whose focus would have been the patient’s motor disturbance. A psychiatrist, by contrast, might have diagnosed that same patient with a form of melancholy, emphasizing the patient’s mood disturbance. Labels varied further according to doctors’ personal preferences for certain terminology. The crying, trembling patient might have been diagnosed with “psychoneurosis” (a general term that Joseph Grasset preferred to hysteria),121 “commotion” (as Gilbert Ballet might have suggested),122 “pithiatism” (as Joseph Babinski certainly preferred), or a host of other labels, such as “war neurosis” or simply “functional weakness.” Labels for more purely psychiatric disorders varied widely as well. A soldier found mumbling in a stupor following a nearby shell explosion, with no recollection of what had happened, might have been diagnosed with “mental confusion” (as Emmanuel Régis recommended),123 “battle hypnosis” (as Gaston Milian suggested),124 or related illnesses such as “dreamlike delirium” or “amnesia.” While some doctors focused on reported symptoms, others focused on observed signs or behaviors, and still others defined diseases by their etiology. Among the most prevalent diagnostic labels used by French psychiatrists for seemingly war-related symptoms was “mental confusion.” 125 The term had a long history in psychiatry. Once equated with stupidity, idiocy, and even melancholy, German and French doctors began to describe it as a separate entity only around the turn of the twentieth century.126 According to Emmanuel Régis, whose psychiatric textbook was frequently referenced by doctors and used by medical students, mental confusion was characterized above all by confusion of ideas but also included loss of expression, fixedness on an object,

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unresponsiveness to questioning, and physical powerlessness. Before the war, mental confusion was thought to develop under the influence of intoxicants (such as alcohol or drugs) or infections (like the flu). But wartime doctors increasingly believed that other physical or mental illnesses could also trigger mental confusion, as could violent emotions, such as intense fears. According to Régis, mental confusion was generally accompanied by some form of amnesia, which could develop suddenly following a physical or emotional shock.127 Soldiers might be unable to remember the trauma itself, events prior to the trauma, or events after the trauma. In some cases, the memory loss was like night falling on the mind of the patient, while in other cases amnesia might be experienced more as a dreamlike twilight. As Georges Dumas later wrote, some men were able to retrieve bits of memories in no particular order, just as a healthy person remembers parts of a dream after waking.128 Total amnesia, said Régis, was rare. Still, in some cases, Régis and other doctors observed patients who could no longer recall their name, rank, place of birth, profession, age, family, or any other facts pertaining to their lives. That was the case for O., a thirty-three-year-old soldier, who was “commotioned” in December 1914.129 In May 1915, when he was transferred to the neuropsychiatric center of doctors Albert Mairet and Henri Piéron, O. was experiencing cutaneous anesthesia as well as an inability to smell, taste, or speak. He also reported complete amnesia: every memory of his previous life had disappeared. Though he could recall how to feed and dress himself, he was unable to remember people, places, or ideas that should have been ingrained in his mind. This memory trouble also impaired his ability to comprehend language. He understood simple words, but concepts such as “man,” “woman,” “day,” and “night” had no meaning for him. O. was observed by doctors over the course of fifteen months, during which time he alternated between phases of improvement and relapse. Though he began to recognize a handful of people, whisper some words, relearn the alphabet, and copy handwriting, he subsequently lost those acquisitions. Then, after hearing other patients talk about their homes and families, O. became curious about his own past. His wife came to see him and took him back to his village to see if it would trigger any memories. Unfortunately, the visit did not go well. An “ill-fated experience” is how his doctors characterized it.130 O. could remember neither his home nor his mother or sister. He was disoriented and discouraged. He said he wanted to return to his true home—the hospital. Georges Dumas reported the case of a soldier whose near-complete amnesia blocked all but the most painful memories.131 “Haudry” was in the trenches

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when the gust of wind produced by an explosion knocked him over and covered him with dirt. He retained consciousness but was immobile and mute. As he looked around him, he saw a comrade who had lost a hand and was crying. He saw another man who was lying on his side with a jet of blood streaming from his mouth. Haudry’s unit charged the enemy after the explosion, leaving him behind, but eventually another soldier arrived to retrieve him. Haudry was able to recall these rather precise and gory details of the moments following the explosion, yet he subsequently remembered very little about himself or his life before the blast. These men—along with Louis, whose case began this section—were diagnosed with some form of mental confusion and amnesia. But their symptoms might have qualified them for other labels, including “shell shock.” The British psychologist and anthropologist Charles S. Myers in early 1915 introduced that term to the medical lexicon, bringing together a range of war-related neuro­ psychiatric symptoms into a single, new classification.132 In an article published in the Lancet in February 1915, Myers presented the case histories of three soldiers whose senses, memory, and excretory functions were disrupted following the explosion of shells close to them.133 A year later, Myers reported additional cases in which amnesia, hemiparalysis, muscle spasms, mutism, constipation, and stupor were evident.134 According to Myers, these cases constituted a new class of illness that arose from the effects of shell shock. But while the term seemed to underscore the role of a physical concussion in the genesis of the illness, Myers recognized that there was a strong psychological component to the disorder. He later concluded that “in the majority of cases the signs of ‘shell shock’ . . . appear traceable to psychical causes.” 135 French doctors were aware of the term “shell shock,” but they chose not to use it, instead preferring existing categories, such as hysteria and mental confusion, or their own inventions, which (like “shell shock”) were meant to reflect the unique circumstances of modern warfare. One of the first of several new labels concocted by the French was “battle hypnosis,” introduced by Gaston Milian early in 1915.136 According to Milian, a doctor stationed at Verdun, modern battles struck men with terror. Soldiers with particularly fragile minds succumbed to that overwhelming terror and fell into a sleeplike, nearcomatose state. Their eyes remained either shut or wide open, staring into space. They made no noise and did not speak. Though their reflexes and heart rate remained normal, they were in a veritable state of hypnosis, not unlike the state of hysterics who had been put to sleep by suggestion or the compression of hysterogenic zones.

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Alfred, a twenty-year-old infantryman who had been employed in peacetime at the Crédit Lyonnais, developed battle hypnosis in 1914.137 He was taken to a hospital in late August, at which time his head was immobile, his eyes fixed at the sky. He did not respond to most questions, but when asked about the battle during which he fell ill, he suddenly became animated. He spoke in a low voice and in bursts, with sighs between utterances. At one point he imitated the sounds of bullets whistling by him. Pretending to hold a rifle, as if ready to charge with the bayonet, he said “Prussians, Prussians,” and then “Trenches, trenches.” Did he have any memory of the battle, asked the doctor? Alfred replied, “Belgium . . . Belgium . . . Germans pushed back. . . . Captain dead, two hundred men dead.” 138 He made a gesture as if he were falling on his side, and then he sighed, tears silently rolling down his face. Over the course of his treatment, Alfred’s hypnotic state receded, but his delirium increased. He played out scenes in which he tried to rescue comrades who had been wounded on the battlefield. Nearly one month after he had first been hospitalized, Alfred finally regained full consciousness. Milian was then able to collect a more in-depth history of his patient, but he found no significant hereditary problems or personal antecedents. The term “battle hypnosis” did not gain popularity among French doctors, however. More popular was another war-related diagnosis that focused on the etiology of neuropsychiatric disorders—“commotion.” The acceptance of the term commotion (or “commotional syndrome”) as a diagnostic category is interesting in several respects. First, it shows that for many doctors, diagnostic decisions were intimately bound to etiological assumptions. Like shell shock, commotional syndrome was defined more by its supposed causes than by its symptoms or signs. Second, the term’s frequent use by French doctors demonstrates the popularity of theories that emphasized the physical nature of warinduced neuropsychiatric disorders. Some doctors believed that neuropsychiatric disorders were the result of organic changes caused by explosions. The idea that a physical commotion could cause neurological or psychological symptoms was not new to the French. According to Régis, the connection between physical injuries and neuropsychiatric disturbances had been observed since antiquity.139 More recently, French doctors, like their counterparts in Britain, America, and Germany, had found that neuropsychiatric problems could develop following the commotion of railway accidents and workplace injuries.140 During the war, however, commotional syndrome included combat-specific elements. Albert Mairet and his assistants defined commotional syndrome be-

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fore the Academy of Medicine in 1915.141 Mairet insisted that the wind from an explosion could produce physical symptoms without leaving any obvious physical wound. The powerful waves of pressure that followed the blasts acted internally on soldiers, causing internal hemorrhages, embolisms, or other minute cellular changes that could lead to neurological symptoms. Subjects might develop sensory, motor, or affective troubles. Some soldiers could also experience amnesia, delirium, hallucinations, or a “loss of apprehension” due to the dreamlike state in which they were left. The emotional shock caused by explosions also worked indirectly on subjects, enhancing their fear and complementing the physical effects of the commotion. According to Mairet, commotion and emotion were distinct phenomena, despite the fact that some doctors confused the two.142 Several doctors offered their own interpretations of commotional syndrome, often disagreeing about the mechanism by which explosions caused symptoms. Paul Ravaut, a Paris doctor whose focus was diagnostic serology, argued that organic lesions were ultimately to blame for the nervous after­ effects of commotion—a fact that could be corroborated by sampling soldiers’ spinal fluid.143 Paul Sollier, a staunch defender of physical interpretations of neuropsychiatric disorders, surmised that within close range of an explosion, the production of noxious gases caused physiological, cellular changes in soldiers.144 At an intermediate distance, the brusque changes in atmospheric pressure caused embolisms and ruptures that triggered neurological symptoms. Farther away still, vibrations, like a flow of electricity, wreaked havoc on the nervous system. Other doctors held more psychological interpretations of commotional syndrome. Gilbert Ballet and Joseph Rogues de Fursac, who manned the militarized wards of the Maison-Blanche women’s asylum outside Paris, argued that there was little difference between the commotional and emotional effects of an explosion.145 The authors reported that “almost all our men commotioned by the wind of a bomb have had intense nightmares, and several have had terrifying hallucinations.” 146 Ernest Dupré, the director of the Infirmerie spéciale in Paris (a psychiatric facility next to the police station where the dangerous insane were frequently taken), maintained the distinction between commotion and emotion.147 Dupré defined commotion as a massive, diffuse rattling of nerves following the vibrations of explosions. By contrast, emotion followed from an internal, psychic shock. According to Dupré, emotion was inherently unrelated to organic changes or injuries. While doctors debated subtle differences between the variations of com-

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motional syndrome, soldiers suffering from that disorder—the commotionné, as they were called—exhibited a similar range of symptoms as soldiers diagnosed with other disorders, including shell shock, battle hypnosis, and mental confusion. Some displayed neurological symptoms, including trembling and asthenia (weakness), while others showed signs of deep emotional trauma that was often manifested symbolically in somatic form. Such was the case for Pierre, an infantryman who suffered from mild alteration of memory and auditory hypnogogic (pre-sleep) hallucinations consisting of the “rumbling of a drum” in his right ear.148 In September 1915, a nearby explosion had completely buried Pierre in dirt. The Germans then charged, and he heard what sounded like the rumbling of drums. Unable to free himself from beneath the earth, but sensing from the rumbling that the enemy was getting closer, Pierre feared that he would be killed or injured. He was finally freed by his comrades, but he lost consciousness and quickly developed the auditory hallucinations that defined his syndrome. While “commotion” was used frequently, the term “trauma,” or traumatisme, was used only sparingly by French doctors. But its infrequent use should not be attributed to its absence in medical terminology. The term existed, though, as Régis’s text suggests, it often referred to physical “shocks, falls, violent blows, fractures, train and work accidents, electrocution, hanging, etc.” 149 Nevertheless, Régis insisted that French doctors had long understood that physical trauma could cause both neurological and psychological disturbances. The connection between physical trauma and psychological problems came into focus during the industrialization of the mid-nineteenth century, when European physicians and surgeons observed the effects of railway and factory accidents.150 British doctors, some of whom worked for railway companies, discovered that the physical trauma of rail accidents could produce neurological symptoms, even in the absence of a verifiable sign of spinal injury. Some doctors concluded that these functional disorders, often called “railway spine” or “railway brain,” were the result of psychic shocks rather than physical injury. In Germany, the neurologist Paul Oppenheim, who called these disorders “traumatic neuroses,” concluded that physical trauma probably did cause minute lesions in the nervous system, though he also conceded that emotional shock could play a major role in the development of symptoms.151 Both British and German doctors also realized the possibility of malingering, however, since insurance legislation that held railway companies financially responsible

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for injuries generated what the Germans would later call “pension neurosis.” Beginning in 1879, Charcot too began to investigate post-traumatic disturbances in men.152 Diagnosing these problems as “hystéro traumatisme” (the label Dejerine applied to R.), “névrose traumatique,” and similar names, Charcot believed that they were essentially manifestations of hysteria. They did not constitute a distinct category of disease, as Oppenheim had suggested. Interestingly, Charcot came to conclude that the emotional shock from generally minor events could be sufficient to cause neurological disturbances, even without an identifiable physical injury. According to Pierre Janet, who trained with Charcot and later became the professor of psychology at the Collège de France and the director of the psychology laboratory at the Salpêtrière, Charcot showed that a disorder could be produced merely by the idea of a physical injury: “It is not necessary that the carriage wheel should really have passed over the patient; it is enough if he has the idea that the wheel passed over his legs.” 153 Janet believed that he was extending Charcot’s ideas by promoting a psychological model of hysteria.154 He argued that the emotional shock of experiencing an physical injury, rape, or incest, witnessing violence or a death, or even hearing the news of the death of a loved one could serve as the trigger for illness. The patient might purposefully conceal the traumatic memory or bury it “subconsciously” (the term Janet preferred). The inability to integrate the traumatic memory was what caused the disorder. The memory might become a subconscious “fixed idea,” the content of which would be expressed—again subconsciously—through the illness. For example, a patient might become subconsciously fixed on the death of his father and then develop a complex array of problems—such as obsessions, anxiety, depression, or hysterical symptoms—that somehow related to the idea of his father’s death. The hidden meaning of the patient’s disorder could be uncovered by his doctor through a detailed case history, careful observation, and extensive doctorpatient interaction. Through a multistage treatment regimen that included hypnosis and psychotherapy (among other methods), the doctor attempted to reveal the underlying memory or fixed idea and then integrate it into the patient’s consciousness. Though Janet contributed little directly to the wartime debates on functional illnesses and other seemingly war-induced disorders, aspects of his psychological model of hysteria, in which emotional shocks triggered illness, were incorporated into the writings of some of the more psychologically ori-

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ented doctors. In some rare cases, writers did use the term “trauma” to signify the types of emotional shocks Janet described. For example, Ernest Montembault, who in 1916 presented his doctoral thesis on the psychological disorders of soldiers, used the word trauma “in a very general sense, including both a psychic and physical sense.” 155 For Montembault, psychic trauma, “which one can call emotional shock,” did not need to be produced by a physical phenomenon, such as an explosion: “It can result from violent emotions [émotions morales], such as fears, grief, unpleasant impressions, the witnessing of scenes of horror.” 156 Psychological trauma might even develop before a soldier saw any fighting. A twenty-two-year-old soldier who was a lawyer in peacetime began experiencing disturbances when he arrived in Paris to join up with his regiment.157 He came to the city during a railroad strike, which no doubt added to the chaos, confusion, and anxiety of his journey. For this young soldier, however, the strike was more than just a series of inconveniences. It seemed to trigger deeper psychological troubles. He developed a delusion that the strike signaled an impending revolution. At first he was merely upset, but then he began to show signs of melancholy and ultimately experienced hallucinations. At some point on this psychic journey, he became suicidal as well. Though he never experienced the physical shock of shell explosions, he nevertheless developed a serious psychiatric condition, which Montembault believed was “traumatic” in origin. The scant use of the term “trauma” among French neurologists and psychiatrists was not, then, due to the absence of the term in the medical lexicon. Nor was it due to an absence of the concept of purely psychological triggers for the malady. The relative scarcity of the term “trauma” was also not the result of a purposeful effort by doctors to minimize the abuse of pension claims. In Germany, where the diagnosis of “traumatic neurosis” could translate into a pension for afflicted soldiers, doctors used the term “hysteria” to protect the state from spurious claims. In France, however, the incorporation of the word “trauma” into a diagnosis did not necessarily dictate a particular pension result. After all, a physical event could cause both a pensionable neurological disturbance and a non-pensionable pithiatic complication. While the term “trauma” never developed the charged valence of “pithiatism” and “hysteria,” trauma—with both physical and psychological components— was nevertheless the concept at the center of medical discourse during and after World War I. Just as they had done for traumatic rail and workplace ac-

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cidents, doctors studied whether and how physical trauma could produce neurological and psychiatric symptoms. They also debated whether purely emotional shocks could generate illness, and they considered that soldiers might be faking for secondary gains.

Causes Maurice Dide, who directed the Braqueville-Toulouse asylum in peacetime and served at the neurological center of Bourges during the war, represented one end of the etiological debate.158 Dide emphasized the crucial role of emotions in the production of neuropsychiatric disorders.159 Writing in 1918, he argued that French physicians had for too long neglected the psychology of emotions in evaluating the causes of mental illness. Dide was willing to consider the possibility that the physical commotions of shell explosions and the physical stresses and strains of military life could cause neurological damage to soldiers. But after his own scientific testing and an extensive review of the scientific literature, he was forced to conclude that wartime illnesses such as hysteria, neurasthenia, and post-emotional psychoses were simply not of organic origin. According to Dide, emotional shocks were the trigger for those disorders. Despite the persuasiveness of his argument, which was backed by wartime experiences and scientific experiments, the organic-based theory continued to remain convincing to many doctors, including some psychiatrists. In 1919, Georges Dumas reevaluated the three major interpretations of wartime neuropsychiatric disorders.160 Dumas was unimpressed with the emotional interpretation that Dide supported. Emotions, Dumas argued, were fleeting, so it was unlikely that they could account for the continuation of symptoms beyond the initial reaction or the development of delayed-onset symptoms. He believed that Babinski’s pithiatic interpretation helped to explain the genesis of many wartime symptoms. Suggestions, not emotional shocks or physical concussions, were to blame. Pithiatism could also account for several cases in which patients delayed their recovery from organic injuries. But for Dumas, the organic interpretation triumphed in the vast majority of cases, even in cases where doctors were unable to find the offending lesion. In addition to debating the causes of war-induced disorders, doctors attempted to determine who might be susceptible to the trauma of war. Could any healthy soldier be so overcome by the violent emotional or physical shocks

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of war that he would develop a neuropsychiatric disorder? Or were those disorders reserved for the predisposed? Many doctors contended that hereditary defects, such as a family history of alcoholism or melancholy, provided the fertile ground necessary for the development of mental or neurological illnesses. Other doctors added that personal, acquired antecedents, such as contagious illnesses, could weaken a soldier and predispose him to illness. Others still suggested that personality, “race,” or social class might determine who would develop war-related disorders. The question of the influence of inherited and acquired weaknesses in the development of mental illness predated the war by a century or more. Physicians in France, and elsewhere, had long used heredity to explain the origins of physical and mental diseases. In the mid-nineteenth century, Bénédict-­Augustin Morel strengthened this position by articulating a process by which defects were inherited.161 Influenced as much by Christian thinking as by Lamarckian theory, Morel contended that original sin had made humans vulnerable to a variety of environmental factors that could cause them to deviate from the ideal, perfect human type.162 Those deviations could be passed down through successive generations and combined with acquired defects to produce a range of mental (or physical) disorders. Because defects were cumulative over generations, Morel characterized this process as “degeneration.” He believed that some families might degenerate over several generations until their extinction. Although later hereditarians dropped the religious aspect of Morel’s theory, many doctors continued to emphasize the importance of both inherited and acquired defects in the production of mental disorders. As the historian Ian Dowbiggin has argued, the strong interest in degeneracy theory among alienists can be attributed in part to their failure to find anatomical answers to the riddles of mental illness. Some alienists had hoped to use post-mortem findings to improve their understanding of insanity, but the dearth of results left them eager to latch onto to a new etiological model that could help demonstrate their worth and retain their connection to medicine.163 In the late nineteenth and early twentieth centuries, doctors believed that contemporary society was replete with the sorts of harmful environmental factors that could weaken an individual’s constitution or exacerbate inherited defects. A contagious illness, such as typhoid fever, could leave an individual prone to developing a mental disorder. At the same time, certain behaviors, such as chronic drunkenness or sexual excesses (which might lead to vene-

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real diseases), could diminish resistance to psychiatric illnesses. Additional environmental factors—such as malnutrition, excessive exposure to the elements, overwork, or loss of sleep—could also prepare the ground for sickness. During the war, neuropsychiatrists continued to assign strong roles to inherited and acquired predispositions in the development of war-induced neuropsychiatric disorders. It seemed impossible to do otherwise. Régis found that almost all men who developed war hysteria had suffered from previous nervous troubles.164 Paul Chavigny contended that soldiers presenting with almost any psychological, neuropsychiatric, or neurotic troubles had predisposing defects.165 Some doctors believed that neuropsychiatric illnesses tended to develop in individuals with certain personality types. Gilbert Ballet wrote that soldiers who exhibited nervous or hysterical symptoms were “emotive.” 166 Régis described these men as “impressionable” and “nervous” types.167 Ernest Dupré argued that individuals with emotional personalities could often be identified through specific physical or affective signs.168 Physically, emotional individuals often had muscular or vasomotor disturbances. Affectively, they tended to express fears and worries; they were habitually pessimistic; they suffered from obsessions and phobias; and they were prone to mental ruminations. Dupré believed that emotional personalities were generally inherited, although he admitted that terrible catastrophes and other environmental factors could also play roles in their development. Several of the doctors who described the personality types of wartime hysterics were influenced by Dupré’s 1905 definition of the “mythomanic” personality type.169 The mythomaniac had a “mythic” aptitude—that is, an aptitude for inventing myths. Dupré argued that a mythomaniac’s inherited tendency toward lying was a personality anomaly. In normal subjects, this mythic aptitude gradually disappeared through moral and social education. In mythomaniacs, however, the aptitude persisted. Dupré distinguished the mythomanic personality type from hysteria, but many French doctors failed to maintain the distinction. Just as Babinski’s pithiatism equated patients with malingerers, Dupré’s inadvertent contribution to the moral judgment of hysterics was to portray them as willful liars. It was part of their personality. When hereditary or personal information was available to wartime doctors, they often found hereditary defects, histories of illness, or unfavorable personality traits in traumatized men. Ernest Montembault presented the case of a melancholic sergeant, for example, who had numerous predisposing factors to

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illness.170 A. was forty-eight years old when he was interned in an asylum for depression, bouts of tears, and attempts at suicide. After interviewing their patient, doctors found that mental illness ran in the family: A.’s mother had been nervous, and his brother also had been interned. According to doctors, A. appeared nervous and had an impressionable temperament. Moreover, he had a history of psychological troubles: he had suffered from two previous bouts of melancholy in the previous twenty-three years. For many doctors, however, the wartime conditions in which they practiced medicine were simply not conducive to collecting sufficient patient information to determine the role of predisposition in the etiology of illnesses. Georges Dumas acknowledged that inherited defects could predispose some patients to functional or psychiatric disorders, but he admitted that during the war he was unable to find enough evidence to prove that hypothesis. Like his front-line colleagues, Dumas was able to elicit very little information from soldiers and none from family members (a valuable source of information for peacetime doctors). Consequently, he was unable to make any correlations between heredity and the onset of mental maladies. Only several years after the war, when he revisited the psychology of hysteria, was he finally able to give a pronouncement on the role of heredity in neuropsychiatric disorders.171 At that time, Dumas confirmed that a person’s constitution—in particular, his or her suggestibility—could play a role in the development of hysteria. Nevertheless, Dumas insisted, heredity alone was not enough to cause the disorder. According to some doctors, a patient’s race—which was more easily identified than his personality type, or his inherited or acquired scars—might also contribute to the susceptibility to certain illnesses. For some time, French alienists in overseas territories had conducted psychiatric studies that examined race.172 Early nineteenth-century doctors believed that “primitives” in Africa and Asia were less prone to insanity because they were less exposed to the corrupting influence of civilization. By the twentieth century, however, doctors had found that primitive peoples did in fact develop psychiatric afflictions, even if those afflictions appeared in different numbers and with subtly different variations than in European populations. The study of comparative ethnopsychiatry that developed, particularly in Algeria, explored the normal psychology of native peoples, the social setting for the psychological development of those native peoples, and the physiological differences between natives and Frenchmen. The work that doctors produced reflected both the relatively underdeveloped state of anthropological and sociological thinking,

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and the comparatively well-developed state of racist stereotyping and imperialist ideology.173 Antoine Porot, who directed the neuropsychiatric center in Algiers during the war, noted that black troops, particularly men from Senegal, rarely developed functional troubles; nevertheless, he saw a certain number of hysteriform reactions “in these large children.” 174 Their disorders were “often childish, crude, disorderly, sometimes amusing, and closer to ingenuousness than simulation.” 175 Among the Senegalese who developed psychiatric disorders, Porot noted that nearly all suffered from a melancholic syndrome with ideas of persecution. They developed fugue states, refused to eat, and often attempted suicide. All of these men, said Porot, required constant surveillance. Creoles, he wrote, were equipped with a “reduced” mental mechanism that might block neuropsychiatric pathologies from developing.176 Still, their fragile nerves and psychic facilities made them particularly prone to “autosuggestion” as well as the mental contagion of hysterics. The credulousness and religious docility of indigenous Muslims made that group susceptible to suggestion as well. He noted that their uncultivated minds and their general passivity, inertia, and fatalism contributed to the development of functional disorders. By contrast, Porot noted that Algerian “Israelites” had active imaginations, capable minds, and realistic outlooks. Still, they possessed anxious, emotive temperaments and a tendency to depression. Furthermore, their lucidity in pathological situations and their constant intellectual activity often led them to exaggerate or fake symptoms. According to Porot, Serbs seemed the best able to cope with the stresses of war. Despite the extreme physical and psychological strains to which they had been exposed, Serbs were able to soldier on with calm resignation, generally without developing illness. While Porot and a few others believed that race could determine who would become ill and what types of symptoms the afflicted would display, some doctors believed that a patient’s social class, peacetime profession, or military rank (which were frequently correlated) might also determine the type of symptoms he would develop. British and American doctors noted that officers suffered mainly from dizzy spells, stammering, and severe exhaustion.177 Infantrymen, meanwhile, were struck with paralysis, amnesia, and mutism. Consequently, officers were more apt to be diagnosed with neurasthenia, while infantrymen were labeled as hysterics. A few French doctors made similar observations. Régis noted that the typically class-defined disorder neurasthenia was particularly prevalent among of-

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ficers.178 André Léri specified that neurasthenics “are almost all officers or reservists belonging to the bourgeois class.” 179 Years after the war, when Rodiet and Fribourg-Blanc presented a comprehensive review of the 25,000 soldiers examined at Val-de-Grâce for wartime neuropsychiatric troubles, they stated that neurasthenia was simply one of the most prevalent neuropsychiatric illnesses among all troops. Still, among the five wartime examples of neurasthenia they presented in their book, one soldier had been a chemistry student, another a pharmacy student, and another a bank employee.180 These were not the farmers or manual laborers who seemed to populate other disease categories. In some respects it is surprising that French doctors did not make more of the differences in symptomology between ranks or social status. After all, the version of degeneracy theory that these doctors endorsed seemed to distinguish individuals with superior breeding and behaviors from the so-called degenerate and morally suspect. Still, the British and American doctors who highlighted the differential symptomology among the ranks often used psychoanalytic conceptions as a basis for doing so. According to Freudian­influenced doctors (then and now), soldiers unconsciously converted their psychological disturbances into somatic symptoms that they believed constituted true illnesses.181 While an officer considered dizziness or stammering to represent illness, a foot soldier considered only paralysis to be a real disability. Soldiers also produced the symptoms that symbolically referenced their rankdetermined responsibilities in the war. By stammering, an officer was calling attention to his role of giving orders, whereas soldiers developed—consciously or unconsciously—symptoms that prevented them from fulfilling those responsibilities. A paralyzed infantryman was unable to leave the trench for another charge. French doctors, who lacked a strong Freudian influence, were not as interested in the connections between the patient’s understanding of illness and the manifestation of his symptoms. If many doctors focused on the range of internal qualities that might make a soldier susceptible to illness, few of them could deny that the stressful, fatiguing conditions of war also played an essential role in the development of neuropsychiatric disorders. Doctors believed that the conditions of war could wear away at a soldier’s constitution, leaving him exposed to physical and mental illnesses, or trigger illness in an already predisposed, constitutionally weakened individual.182 Some doctors suggested that the conditions of war alone might be sufficient to cause illness. Raoul-Louis Benon, who served as a

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military doctor during the war and as a staff physician at the general hospice of Nantes, argued that too much emphasis had been placed on predisposition in the development of wartime disorders.183 According to Benon and others, it was the poor food, lack of sleep, and perpetual exposure to the elements that fostered disease. If Babinski’s pithiatism carried a strong element of moral condemnation, this etiological model eliminated that judgment. Most doctors, however, chose the middle path. Henri Vatar, a medical student who served as an auxiliary doctor in the artillery units of the Seventh Region, wrote that it was the combination of personal antecedents and a grueling existence in the trenches that produced neuropsychiatric symptoms.184 Hereditary defects or a life filled with harmful or risky behaviors, such as alcohol abuse or sexual indiscretions, put men at risk for a range of disorders. Without the influence of the war, many men with predispositions might have remained healthy. But doctors also concluded that without a predisposition, the war alone rarely caused mental illnesses. Those conclusions were reinforced by Rodiet and Fribourg-Blanc after the war.185 They argued that the physical fatigues, intoxications, and organic troubles caused by the war were responsible for causing many cases of mental illness. Still, inherited predispositions, constitutional weaknesses, and emotional temperaments could be found in almost all of the cases. Implicit (and sometimes explicit) in the medical debates surrounding the causes of war-induced neuropsychiatric illnesses was the question of re­­spon­ sibility. What was the role of the war in the genesis of illnesses? Was there something about modern warfare that caused illnesses to erupt? Was it the explosion of bombs, the stress of combat, or the deprivations endured in the trenches? If the war was not responsible, what—or who—was? For many doctors, the responsibility for war-induced disorders laid squarely with their soldier-patients. Patients who were declared pithiatic were faking, either consciously or unconsciously. As a result, they were not due any of the rights, privileges, or monetary compensation earned by their comrades. Soldiers with constitutional predispositions to pithiatism or any other neuropsychiatric illnesses were only slightly less culpable. Those with acquired weaknesses—the result of alcoholism or sexual excesses, for example—certainly did not escape blame and moral condemnation. Those with inherited defects, who might seem to have avoided judgment, were nevertheless considered defectives who stood to sap the collective strength of the nation. Whoever or whatever was to blame for these illnesses, it became clear to

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doctors that the war did not have the rejuvenating effects that many people expected. The war was supposed to be an invigorating male experience that could revitalize, even re-masculinize, French men and help rebuild a failing French society. But instead of curing the nation of its degeneration, decadence, and decline, the war instead brought to light more hidden defects.

Conclusion Neurologists and psychiatrists continued to publish works on wartime neuro­ psychiatric disorders after the armistice, but a new epidemiological challenge captured their immediate attention in the postwar period. Between 1917 and 1927, 5 million Europeans either died or were left permanently impaired by a mysterious new disease called encephalitis lethargica (the “sleeping sickness” that initially afflicted the Parkinsonian patients in Oliver Sacks’s Awakenings).186 Like many of their entrenched wartime comrades, patients suffering from this form of encephalitis exhibited a variety of bizarre neurological and psychological impairments, ranging from lethargy, catatonia, motor disturbances, anesthesias, and paralyses to delirium, amnesia, and confusion.187 Auguste Marie, who directed the admissions bureau of Paris’s Sainte-Anne asylum, noted that encephalitis lethargica was simply unknown in medicine.188 For doctors, it was another new riddle to be solved. Interestingly, that riddle helped to sustain debates on functional illnesses throughout the interwar period. Struggling to understand the etiology of encephalitis lethargica, this disease French doctors compared to a wide range of other diseases with which they were more familiar, including hysteria. Because encephalitis seemed more clearly to be the result of an organic process, some doctors expressed renewed interest in organic, neurological interpretations of hysteria. Well into the 1930s, however, there was still no consensus on the etiology of functional disorders. Complicating the debate, the small community of psychoanalysts that emerged in interwar France claimed that hysterical manifestations were the result of real or imagined traumas a person had suffered in infancy. These traumas could reside in an individual’s psyche for a long time, like a foreign body, repressed from consciousness. Ultimately, when symptoms did appear, they did so in some indirect, symbolic relationship to the original trauma.189 Though French psychoanalysts did not weigh in on the debates about wartime illnesses, their position on trauma deepened the divide between somatists and psychologists.

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By the outbreak of the Second World War, not all of the questions raised by First World War had been answered. But some trends did emerge in neuropsychiatric thinking. First, many doctors had come to agree that patients with functional illnesses were not truly injured. Either consciously or unconsciously, these men had produced symptoms that might win them a reprieve from the front. Second, the vast majority of neuropsychiatric illnesses developed in soldiers who were in some way predisposed to them. The war may have helped uncover those illnesses, but it alone did not cause them. Finally, as doctors gained some perspective from the war, many concluded that it did not in fact produce new forms of illness. Categories such as “commotional syndrome” or “battle hypnosis” could be subsumed under existing categories. Did doctors succeed in their professional aims? Not entirely. At the war’s conclusion, they had not clearly solved all the riddles of the seemingly war­induced neuropsychiatric illnesses, despite having had access to so many cases. And while many doctors claimed high cure rates in their neuropsychiatric centers, they did little to halt the development and spread of war-induced disorders. Ultimately, doctors did not overwhelmingly demonstrate their expertise or the important contribution they could make to the French nation. Nevertheless, doctors did not abandon their aims. In the years that followed the First World War, they continued to use the war and its effects to support their professional goals. Neurologists and psychiatrists insisted that, as experts, they were the best qualified to define pension schedules for neuropsychiatric disorders. At the same time, psychiatrists argued that the war had produced an army of traumatized individuals whose cure—which was essential for revitalizing the nation—necessitated the construction of new, medicalized psychiatric facilities. As doctors pursued those professional goals, their patients were largely left behind. When the Great War ended, many men who had been diagnosed with neuropsychiatric disorders were discharged from the military and released from medical care—allegedly “cured.” Meanwhile, individuals who had been classified as chronic psychiatric cases were either transferred to public asylums, if their conditions warranted internment, or released to their families, who had to bear the burden of these “human wrecks.” In addition to the struggle to overcome the psychological trauma of war, these veterans had another battle ahead in the postwar years: the fight for pension allocations. Although France introduced a new pension law in 1919 that attempted to extend greater compensation to a larger number of its wartime heroes, those allocations were often insufficient to cover living expenses,

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especially given the fast-rising cost of living in postwar France. For mutilés (physically wounded men), the pension situation was dire. Unable to return to work, many depended on pensions to survive. For veterans diagnosed with functional illnesses or psychiatric disorders, the situation was grimmer still. Most received, if anything, only a small pittance for their illnesses. Some were left unable to hold gainful employment and became completely dependent on their families, who, as we will see in the next chapter, were themselves struggling to overcome the psychological trauma of war.

Chapter 2 Surviving the Home Front

Mademoiselle D. was seventeen years old in August 1914, when the sound of approaching cannons forced her, her family, and other townspeople to flee their northeastern French village of Saint-Quentin for the interior.1 The exodus was plagued with troubling incidents: one member of her family suffered convulsions, and other members of the group were nearly crushed by a train. But the convoy marched on, spurred by stories of atrocities committed by the invading German army. D. arrived in the Seine department by mid September. Though it is possible that D. sought psychiatric care voluntarily, it is more likely that she was brought to doctors by members of her entourage or the police. She was evaluated at the Infirmerie spéciale in Paris—the examination and holding center near the central police station. Ernest Dupré, the facility’s director, found D. to be semi-confused, excited, and incoherent, with severe mood swings and flights of ideas. She was transferred to the central admissions bureau for Paris mental institutions, located at the Sainte-Anne asylum. Marcel Briand, the admissions director, admitted D. to Sainte-Anne, certifying that she showed “mental confusion, alternating depression and excitation, [and] incoherent comments.” 2 Interestingly, Briand suspected that she suffered from a thyroid condition, given several of her physical signs, including an accelerated pulse and trembling hands. At the beginning of her asylum stay, D. was violently agitated, exhibiting contortions and dancing wildly. She slept little and was constipated. Though her case history does not mention any specific therapy, she probably benefited

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most from rest and proper nutrition. By early November, her condition had improved considerably. D. eventually began to recount to her doctors the visions that she had experienced during her long journey and her stay at the asylum. “It was like a dream,” she said. I saw some fire, smoke, I heard the cannon. It seemed to me that I was taking part in a battle, that I was Joan of Arc, that I should save France. When I climbed into bed, it was because I believed I was on a horse and that I was firing shots at the Germans. At other times, I thought that I was home. Some people from back home were speaking to me and saying that the war was over. I would talk with them. Sometimes, I found myself in a convent. I was [mis]taking the nurses for nuns. I thought I saw my aunt here, who is a nun.3 D.’s condition appeared to have been brought on solely by emotional shocks, but Madame Imianitoff, a Paris medical student who presented D.’s case in her 1917 thesis, underscored the contribution of somatic factors, including the physical stresses of D.’s journey. Imianitoff also discovered personal and familial antecedents that helped to explain D.’s behavior. From D.’s parents, doctors learned that when D. was eleven, she had suffered from chorea—a neurological condition characterized by involuntary movements that provided a precedent for her contortions and dances at Sainte-Anne. D. also had an epileptic cousin, a fact that suggested that she might have had an inherited predisposition to neurological problems. Imianitoff’s thesis on the role of emotions in the genesis of mental illness was not published widely, but doctors referenced it frequently for years to come. Examining cases of women admitted to Seine asylums through the central admissions bureau during the war, Imianitoff investigated the psychological impact of the war and evaluated its role in the development of “durable psychoses” (lasting psychological disorders). In many cases, such as D.’s, Imianitoff found that emotional trauma acted the most strongly on predisposed individuals. Mademoiselle D. was fortunate enough to have received the medical care— or at least the food and rest—she needed after a harrowing journey. But she was an exception. Most civilians who suffered from apparently war-induced disorders did not receive any care during the conflict. Admissions to French

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mental asylums declined during World War I, just as they had during previous military, social, and political upheavals. Researchers during and after the war explained that trend in terms of demographic shifts and administrative disruptions. Civilians moved from cities, where psychiatric facilities were easily found, to the relative safety of the provinces, where institutions were fewer and farther between. In addition, many asylums curtailed services or closed their doors as doctors and staff abandoned civilian facilities to contribute to the war effort. Other institutions were requisitioned by the military for wounded soldiers. The government, the military, and the medical community directed their resources first and foremost to the war effort; insane civilians were left to fend for themselves. For the doctors who continued to treat civilians during the war, their cases (like those of their military counterparts) provided useful material for the study of mental illness. Doctors had been interested in the role of war in the genesis of mental disturbances among civilian populations for nearly a century. As with cases of traumatized soldiers, traumatized civilians offered doctors a wealth of information for an ongoing discourse on the causes of mental illness. How did wars and social upheavals affect the minds of civilians? Who was most susceptible? Nineteenth-century researchers had contended that the release of emotions during war could generate a profusion of mental illness even in an otherwise healthy population, but doctors studying civilian cases during and after World War I were forced to revise that conclusion.

Revolutionary Passions The study of war-induced illnesses among civilians has a long history in France. For nearly a century before World War I, French medical doctors, psychologists, and sociologists had attempted to determine whether and how wars— as well as other social, economic, and political crises—affected the mental health of civilians. In a country that endured so many upheavals throughout the nineteenth and early twentieth centuries, researchers had frequent opportunities for study. Above all, researchers hoped to better understand the etiology of mental illness. Because civilians were less frequently exposed to the physical danger of war than soldiers, researchers focused their study of civilian trauma on emotional or psychological triggers. Philippe Pinel believed that “passions” (somewhat akin to emotions) played a key role in the genesis of mental diseases.

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He reasoned that periods of emotional excitement, such as revolutions and wars, would generate surges in the incidence of mental illness. According to Pinel, a revolution could provide a favorable atmosphere for stirring up human passions and producing mania in all of its forms.4 That etiological thinking influenced a string of medical publications that followed significant nineteenth-century events.5 In the wake of the 1870–71 Franco-Prussian War, Ludger Lunier, the French inspector general for psychiatric services and chief editor of the leading French psychiatric journal, the Annales médico-psychologiques, conducted an extensive study that attempted to measure the role of the war and subsequent sociopolitical upheaval in the development of mental illness among civilians.6 Though the military engagement was a relatively brief affair, the crises that followed—including the blockade of Paris, the formation and repression of the Commune, and the occupation of French territory—placed severe mental and physical strains on French citizens. Lunier and others suspected that the war and subsequent events had left indelible marks on the minds of French men and women, especially those in the invaded and occupied eastern territories and in the beleaguered capital. Like many nineteenth-century alienists who hoped to imbue their work with science and legitimacy, Lunier placed statistics at the center of his research. Statistics had begun to play a central role in medical research during the birth and development of hospital medicine in late eighteenth- and early nineteenth-century Paris. In large city hospitals, doctors were able to conduct extensive statistical studies much more easily than through private practice. Doctors counted hospital admissions, tabulated the incidence of specific disorders, totaled deaths, and even collected meteorological data, which they attempted to correlate with disease outbreaks. They published statistical reports in medical journals and presented them regularly to departmental administrators. Since the time of Pinel, alienists had also adopted this approach to the study of disease. Though no statistical methods were employed beyond calculating simple percentages, alienists nevertheless saw the collection and reporting of data as essential components of producing scientific studies.7 To assess trends in the incidence of mental illnesses after the Franco­Prussian War, Lunier collected data on admissions to mental asylums from numerous institutions across France. He suspected he would find subtly different trends in occupied territories, evacuated territories, invaded territories, and regions that were located far from the fighting. In Lunier’s methodology, a rise in admissions would have signified a rise in mental illness.

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Unfortunately, one of Lunier’s key assumptions—that the patients admitted to asylums represented the larger population of citizens with mental problems—was suspect. It is true that in an era when alternatives to asylum care were limited, many mentally ill people were interned in asylums. But not all mentally ill people sought or were subjected to institutional care. Some were simply kept at home. Working-class families, who could not afford the private care offered to the wealthy in private clinics but who still wanted to avoid the legal and emotional scars of internment, often assumed caretaking responsibilities for their troubled relatives. Especially for patients with milder ailments, home care was an obviously preferable alternative to the neglect of massive, dirty asylums. But alienists in the 1870s made little effort to track the prevalence of mental illness beyond asylum walls, and researchers such as Lunier were left to generalize from asylum trends. Following the theoretical legacy of Pinel, Lunier expected to see a rise in mental illness during the Franco-Prussian War and its aftermath, especially in territories close to the action. But his data showed that during the period of the greatest turmoil, admissions to French asylums nearly everywhere decreased. This finding was all the more remarkable because asylum admissions throughout France had risen fairly steadily every year before the war. Lunier had two explanations for his discovery. First, disruptions in departmental administrations restricted the number of possible admissions. In an effort to reduce wartime costs, some departments purposefully admitted fewer patients. Other departments were so disrupted—first by the war and then by the Commune— that they were unable to carry on business as usual. Second, Lunier argued, great sociopolitical upheavals had the power not only to produce new triggers for insanity but also to suspend triggers normally present during times of peace. According to this argument, which Lunier derived from a statement made by Jules Baillarger after the Revolution of 1848, any influx of new admissions due to current events would be offset by a reduction in admissions due to the absence of more typical stressors.8 To rescue the theories of Pinel, Lunier presented evidence that the strong emotions engendered by the war and subsequent crises still produced numerous mental disturbances. Though there was an overall drop in asylum admissions, he admitted, a large percentage of the patients who were admitted to French asylums during and immediately after the war had been directly affected by the events of that period. In support of his claim, Lunier noted that the ratio of manic cases to depressive cases was significantly altered during the turmoil: many more civilians than usual became manic. Patriotic exci-

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tation, news of France’s defeat at Sedan, the bombardment of Paris, and the strong emotions generated by the siege of Paris all contributed to these mental disturbances. According to Lunier, there was a resurgence of admissions to asylums in the years following the conflict, continuing the upward trend that had been interrupted by the war. Lunier suggested that many aliénés had stayed with their families during the war and the Commune. With the resumption of some form of normal administrative functions and social activity, those troubled men and women were once again placed in asylums. The influence of Lunier’s work was felt long after it first appeared in print. Researchers undertaking similar studies before, during, and after World War I used Lunier’s report as a guide for their own research. Several adopted Lunier’s methodological approach and repeated Lunier’s explanations for their statistical findings. Even those who disagreed with Lunier’s conclusions used his work as a benchmark for their own research. Adam Cygielstrejch’s 1912 study, which was published in the Annales médico-psychologiques, continued the discourse that had begun with Pinel and Esquirol and was extended by Lunier.9 Cygielstrejch was a Polish doctor who examined the psychological effects of the Russo-Japanese War on soldiers and the Russian Revolution of 1905 on civilians. Surveying the reports of Russian doctors, Cygielstrejch echoed Pinel and Lunier by arguing that emotions played a significant role in the genesis of mental illness. According to Cygielstrejch, sudden emotional shocks, such as those that followed earthquakes and railway accidents, gave birth to transitory mental disturbances, particularly when acting on favorable hereditary terrain. Durable emotions, such as those triggered by political commotion, produced deeper, more long-lasting effects. While Cygielstrejch attributed a strong role to emotions in the creation of mental illness, he also admitted that most Russian writers assigned a primary role to hereditary predisposition. Cygielstrejch himself ultimately wavered on the fundamental cause of mental illness. He concluded that it would be impossible to know whether emotion alone, in the absence of a predisposing factor, was capable of producing psychopathology. Reflecting on Lunier’s methodology, Cygielstrejch disputed the usefulness of asylum admissions in gauging larger trends in mental illness, but not because asylum populations failed to represent all psychologically troubled citizens. Rather, he asserted that the long development of many mental diseases

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prevented trends from becoming easily apparent in admissions statistics. According to Cygielstrejch, a decrease in asylum admissions during a time of crisis did not indicate the absence of that crisis’s psychological impact on individuals. Mental illness could appear with a delayed onset. Cygielstrejch wrote, “Ordinarily, during the periods of political trouble, the number of internments diminishes; it augments on the contrary after these periods.” 10 Some illnesses developed slowly and progressively a long time after the event.

The War Calixte Rougé was one of just a handful of doctors during the war who attempted to describe the impact of war on both soldiers and civilians.11 Rougé directed a remote asylum in Limoux, which served the southwestern departments of Aude and Pyrénées-Orientales. Though the asylum was far from the front, Rougé saw a fair share of soldiers. The asylum also continued to receive civilian men, women, and children throughout the war. Like Lunier and other nineteenth-century predecessors, Rougé attempted to measure the psychological impact of the war by comparing admissions statistics from one year to the next. He believed that the “incontestable” method of collecting statistics, combined with the careful observation of numerous patients over time, could yield impressive scientific results.12 According to Rougé, this methodology was responsible for some of the greatest medicoscientific findings, including, for example, the differentiation of typhoid fever from other fevers. Rougé realized that his limited sample size could produce a study of only “mediocre” importance, but he hoped that his findings could be replicated in other asylums to create a complete picture of the psychic troubles of French men and women during the war.13 Rougé believed that such research would produce an important collective work, since the current war produced more, and more varied, illnesses than past wars or political upheavals. Again like Lunier, Rougé found that his asylum’s population failed to rise significantly during the war, despite the upward trend from the years preceding the conflict. Though the number of men admitted rose slightly, military personnel originally from other regions accounted for a large percentage of admissions. There was no significant rise in the number of civilian men admitted from the two departments the asylum typically served. At the same time, the number of women admitted to his asylum during the war diminished compared with prewar years. Rougé did not attempt to explain the de-

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cline in admissions for his facility, but he noted that private asylums (such as his) typically saw admissions decline because families’ fortunes changed during sociopolitical turmoil. Having observed the individual cases in his asylum, Rougé initially entertained the idea that passions, or emotions, could play an important role in the development of illness. He found that many of the men admitted to his asylum suffered from a form of patriotic excitement, often accompanied by alcoholic intoxication. Men, it seemed, reacted to the stress and agitation of war by getting drunk and becoming manic. One excited man, for example, left his home with the intention of confronting Germans, whom he believed would pass through Spain to invade France. He wanted to fight them “with some heart, without weapons.” 14 Emotions also seemed to be the primary trigger for P., a fifteen-year-old boy who was admitted for a breakdown following his father’s departure for the front. P. had no hereditary defects, nor had he suffered any previous bouts of illness. Soon after his father left for the war, P. became agitated and began to display disordered thoughts, extravagant acts, and a preoccupation with the war. He would utter unfinished phrases, such as “country in danger, needing to be saved . . . justice . . . punish shirkers . . . leave . . . take my father’s place.” 15 Sometimes he would sing patriotic songs at the top of his lungs. Other times he would curl up in a corner of his room. Gradually he began to suffer visual and auditory hallucinations: he conversed with St. Peter and refused to climb into his bunk because, he said, a cadaver was laying there. His mental state continued to deteriorate, and at one point he attempted suicide by trying to strangle himself with his scarf. Many of the women admitted to Rougé’s asylum reacted to the departure of husbands, fathers, and sons with “sad emotions” that might lead to agitation, manic excitation, mental confusion, melancholic stupor, simple melancholy, or agitated melancholy.16 In the twelve cases he studied, Rougé found depression in half of the cases and excitation in the other half. Despite the important role of emotions in the development of his patients’ mental troubles, Rougé ultimately admitted that emotions alone rarely produced illness. In nearly all cases, prior problems or some sort of a predisposition to illness could be found. Among all women, he noted, “predisposition had not lost its prerogatives [droits].” 17 Of the twelve women he reviewed, two had hereditary defects, two had demonstrated mental troubles before the war, and two had been interned previously.

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Rougé reached similar conclusions for many of the men he observed. For example, a sixty-four-year-old man admitted to Rougé’s asylum had previously suffered mental troubles following a fall in which he injured his head. He had fully recovered and had been in good health for some time, but then his son left for the war. When the man learned that his son had become ill in Lyon, he began to develop a mental disturbance. At the time of the man’s admission to the asylum, he displayed mental confusion, along with agitation and complete disorientation. The man also refused to eat for fear of being poisoned. While recent events might have led to this asylum commitment, his prior illness, Rougé seemed to argue, could not be ignored.18 Like Lunier and Rougé, Imianitoff first attempted to find trends in the incidence of mental illness by evaluating admissions statistics. Examining statistics for women admitted to Seine asylums over the first three years of the war, she saw a rise in entrances. However, she was careful to note that the rise was more gradual during the conflict than it had been during the three years that preceded the war. Imianitoff hypothesized that admissions continued to increase because many families chose to place their troubled sisters, daughters, and mothers in the safety of an institution before leaving Paris for the provinces. Ultimately, Imianitoff was forced to conclude, as Rougé had, that a predisposition to illness was generally necessary for mental illness to develop. In case after case, Imianitoff found that emotions alone were not enough to generate durable mental illnesses. Only when emotions acted on predisposed terrain—either hereditary defects or constitutional “disequilibriums” caused by fatigue, malnutrition, or other physical stresses—would women develop severe, lasting disturbances.19 Though a predisposition to illness seemed necessary for the development of long-lasting disorders, some doctors maintained that the terrors of war experienced directly by civilians did have the power to trigger temporary psychological disturbances in otherwise healthy individuals. And unfortunately, those terrors were not relegated to eastern territories. Even Paris—the safe haven to which so many French and Belgian citizens traveled from the battle zones—was in reach of the German war machine. Zeppelins frequently flew reconnaissance missions over the city. By 1918, the Germans struck directly at Paris with zeppelins, planes, and their newly developed long-distance cannon, Big Bertha. Bombs fell on hospitals, stores, and apartment buildings. Air raid sirens sent Parisians scrambling to safety in cellars and underground metro stations.

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The American lawyer, suffragette, and wartime journalist Madeleine Z. Doty wrote that Parisians endured these terrifying attacks with great courage and even humor: “This forced exodus to the cellars Paris treats as a joke. With characteristic pluck and good humor the French dressmakers are designing models for underground wear; fur lined silk negligées, that can be slipped on at a moment’s notice. Even underground moving picture shows and restaurants are in order.” 20 Nevertheless, the shellings brought civilians directly into contact with the war and the attendant psychological strains that produced neuropsychiatric conditions among so many soldiers. Doty admitted, “It is not easy to live always in the presence of air raids and bombardments. The tension gets on one’s nerves. To daily face death one needs courage and sanity.” 21 Doty insisted that the French possessed both of those qualities, but, clearly, there were some individuals for whom the stresses of war were too great to bear. At the Salpêtrière, Philippe Chaslin reported that a large number of civilian cases in 1918 were related to the strains of war and, more specifically, to the terror produced by the total war unleashed on Paris by the Germans: “The large number of mental troubles classed under the name organic deliria is, without any doubt, due to the material and emotional [morales] conditions brought about by the war. Fatigue, deprivation, emotions, and particularly the bombardment by planes and big cannons have produced, in a lot of women, states of exhaustion that caused, often aided by the flu . . . mental troubles.” 22 Fortunately, according to Chaslin, most of these cases were mild, temporary, and curable.

Suicide Even if the majority of civilians survived the war without physical injuries or rattled nerves, few could escape the psychological pain of losing loved ones. As the historians Leonard Smith, Stéphane Audoin-Rouzeau, and Annette Becker have noted, each single death created a ripple effect among the surviving population. Extended families, friends, neighbors were all touched by grief. These historians estimate that France’s total death toll of 1.3 million could have easily left 39 million people in some degree of mourning.23 Grief, of course, is not necessarily a pathological state. Certainly the vast majority of French men and women left in mourning did not develop mental illnesses. Though their pain and sadness might have felt severe and have lasted for years, it did not severely disrupt their ability to function. But what about

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the other end of the continuum? How severe might survivors’ grief have been? Could grief drive otherwise healthy individuals to desperate acts? In February 1915, Madame O., a thirty-one-year-old Parisian woman, was picked up by the police near a lake at the Bois de Boulogne as she contemplated suicide by drowning.24 Her husband had been killed in battle four months earlier. Since then, she had exhibited profound sadness, anxiety, and despair. She cried often, had a desire to die, and considered suicide, though she had made no serious attempts to kill herself. When she arrived at the Sainte-Anne admis­sions bureau, her physical state was notably weak. Not having eaten in several days, she appeared pale and thin. She had fetid breath, according to her examining physician, and she reported digestive problems. Explaining her lack of eating, she said, “Since I did not have the will to drown myself, I had decided to let myself die from hunger.” 25 Madame O. was well oriented to time and place, but her depression seemed severe, and she cried frequently. Sent to the Villejuif asylum, where she was placed under the care of Édouard Toulouse, Madame O. stayed only briefly before she was able to leave, apparently cured of her troubles. Madame O. was not alone among French civilians in wanting to end the grief and anxiety caused by the war through suicide. But how common was suicide? Psychiatrists and sociologists studied not only the relationship between suicide and the war, but also the relationship between suicide and mental illness. Could war push civilians to this desperate act? Were suicidal civilians mentally ill or simply severely distraught? In France, few formal studies of suicide could avoid the legacy of Émile Durkheim, who, in the late nineteenth century, composed what is still considered one of the fundamental texts of sociology: Suicide: A Study in Sociology.26 While other writers had argued that mental alienation, race, or inherited defects could explain suicide, Durkheim maintained that the primary causes for suicide were social. Specifically, he asserted that suicide resulted from the poor integration of an individual into society. By presenting statistical evidence and using correlational reasoning, Durkheim’s argument appeared at the time to rest on a firm scientific basis. Durkheim refuted the notion that great political or military upheavals would lead to an increase in the number of suicides. He showed that during the revolutions of the nineteenth century, suicide rates declined in France, as they had during crises elsewhere. Other writers had maintained that declines were the result of military drafts or disruptions in administrative record

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keeping, but Durkheim believed that those explanations were inadequate. The phenomena were too widespread to be the result of administrative problems, he argued. The absence of men from the statistics was likewise a poor explanation, since suicide decreased in women as well. Furthermore, the shock of catastrophic events lasted longer than administrative disruptions or periods of conscription. Thus a rise in suicides should have been evident in statistics years after the events occurred. As an alternative explanation, Durkheim suggested that sociopolitical disturbances roused collective sentiments, stimulating partisan spirit and patriotism, and causing a strong integration of society. Suicide, which resulted from a lack of social integration, thus diminished during these times. In the decades following Durkheim’s groundbreaking work, several other French writers revisited the question of suicide. Participants in the mental hygiene movement, which strove to bolster the mental health of French men and women and reduce the incidence of mental illness through early, prophylactic treatment, more closely examined the connections between suicide, social upheaval, and mental alienation. In 1926, Suzanne Serin tackled the question of suicide armed with more in-depth information on the personal histories of the people who constituted suicide statistics.27 Serin worked at Édouard Toulouse’s open psychiatric service at Sainte-Anne, which attempted to track and treat potential mental patients before institutionalization became necessary. One component of the facility (which is the focus of Chapter 5) was a social service designed to identify social causes of mental alienation. Social workers questioned patients about their living situation and occasionally went to patients’ homes to investigate further. For her study on suicide, Serin and her fellow social-service workers noted suicides listed in daily papers and tracked down surviving family members to ask them for additional information about the lives of the loved ones they had lost. Serin found that one-third of the 420 suicides investigated in 1925 and 1926 were not the result of mental illness. Rather, those self-inflicted deaths were a consequence of “private grief” [chagrin intime] resulting from a range of life changes, such as widowhood, abandonment, “amorous deception,” the loss of a child, reversal of personal fortune, or painful illness.28 Though these changes caused grief, according to Serin, expressions of that grief did not constitute psychopathological affections. In only a small number of suicides could Serin positively identify mental illnesses such as depression, alcoholism, delirium, or precocious dementia. Though Serin did not address Durkheim’s work directly, her study supported

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a key aspect of the sociologist’s theory: Serin found that suicide was not highly correlated with mental illness. But while Durkheim—a sociologist—believed that suicide was the result of social factors, Serin—a future psychiatrist— remained focused on the individual. According to her, personal grief was the primary factor in many suicides. Of course, much of the grief suffered by those hopeless souls involved the loss of a close social relationship—either a spouse, a lover, or a child. Durkheim might have argued that those losses effectively severed ties between the troubled individuals and important members of social networks. Serin’s work did not examine the effects of losses from the war, but many of her examples of grief could have been produced by a military conflict. Her work thus raised the question of whether the grief of war—of which there was no shortage during the Great War—could trigger an increase in suicides. Maurice Halbwachs, a French sociologist and early follower of Durkheim, addressed that question when he revisited Durkheim’s work in 1930.29 In his study, Halbwachs intended to justify the use of official statistics in the discussion of suicide, reexamine Durkheim’s work in light of more modern statistics, and revise Durkheim’s theoretical conclusions. Whereas Durkheim had argued exclusively for the social causes of suicide, Halbwachs contended that the psychological (or psychopathological) and the social were intertwined. Ultimately, he concluded that only a fraction of suicides occurred in people who could be deemed psychopathological. In most cases, however, at the moment of suicide, there was a sort of psychological dissociation from the world. For a variety of external or internal reasons, the individual became momentarily disconnected from his or her milieu. In his discussion of the effect of wars and political crises on suicide, Halbwachs noted a clear drop in suicides during the First World War to a low in 1917, seemingly confirming Durkheim’s prediction. Halbwachs, however, disputed Durkheim’s explanations for similar phenomena during previous conflicts. While Durkheim had maintained that wars created patriotism and promoted a stronger integration of society, thus preventing suicides, Halbwachs noted that wars also caused major disruptions in societal structure and people’s daily lives. Economic and professional activities were fractured, families were torn apart, and there were fewer contacts among individuals. Halbwachs found the same types of social dissociations—and the same declines in suicide rates—when he surveyed other political and economic crises of the nineteenth century. For Halbwachs, those facts indicated that the level of social integration alone could not account for suicide trends. Still, Halbwachs

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maintained that mental illness did not entirely explain suicide either. He concluded that trends in insanity (as indicated by asylum admissions) and suicide were not necessarily correlated. Referring to Serin’s study, he noted that only one-sixth of reported suicides were unquestionably psychopathic acts. In the end, he disappointingly abandoned the debate, insisting that all hypothetical explanations take a back seat to statistical facts. As he wrote, “The main point is . . . suicides diminish in times of political crisis as well as during wars. This fact must be held on to whatever explanation one might give for it.” 30 The American sociologist Walter Lunden corroborated Halbwachs’s statistical findings in 1947.31 He found that suicides in Paris and in France declined from the beginning of the war, reaching a low in 1917. Suicides then climbed back up dramatically in the 1930s, a fact that Lunden attributed to “the return of civil life with the added maladjustments [of] postwar years,” including “years of unemployment, bank and business failures, such as the Stavisky Exposé, poverty, and general economic misery.” 32 Suicides reached a peak in 1934. Though Lunden believed that the peak was due to postwar social and economic problems, he insisted that in any population, a certain number of individuals might commit suicide given specific conditions. Once those conditions came into play and those “weaker persons have been swept away” by suicide, the number of cases tended to drop again.33 How should the case of Madame O. be explained? Imianitoff, in whose thesis the case appeared, counted Madame O. among the mentally ill. But Imianitoff argued that the emotional shock of losing a husband was not the sole cause of Madame O.’s illness. First, Madame O. appeared to have a weak, emotive constitution. Somehow able to distinguish their patient’s present symptoms from her deeper personality traits, Madame O.’s doctors noted that she was very nervous, impressionable, and inclined to despair. But more importantly, the patient showed signs of epilepsy. During her stay at Villejuif, she had two crises in which she lost consciousness, convulsed, and foamed at the mouth. Her face and lips turned blue, indicating a loss of oxygen. Madame O. had no memory of either event. Imianitoff concluded that the patient’s emotive constitution, coupled with her epilepsy, predisposed her to mental illness. That illness led her to contemplate the ultimate escape from pain.34

The Aftermath In the years after the war, as psychiatrists gradually returned to their peacetime posts, additional doctors contemplated the impact of war on civilian

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populations. While many wartime doctors had concluded that inherited or acquired predispositions were a necessary ingredient for the development of psychological disorders among both soldiers and civilians, postwar researchers continued to consider the possibility that the war alone might have been sufficient to cause mental illness. Why did they persist with that line of thinking? After all, the conclusion that only the predisposed succumbed to illness might have been reassuring: it might have meant that the vast majority of individuals could have endured the stresses and strains of war without any lasting psychological side effects. Doctors continued to consider the war’s influence in the genesis of mental disturbances in part because studies that highlighted the prevalence of inherited defects or acquired weaknesses among French citizens did not support the national cause. During the war, many doctors did not hesitate to label traumatized soldiers as weak-willed shirkers if it served their therapeutic goals, but they were careful not to portray the army publicly as a collection of alcoholics, syphilitics, or mental defectives. After the war, the French people needed rejuvenation, not the refrains of the last century, in which hereditary scars, social blights, and bad behaviors were continually blamed for what was widely perceived as national degeneration. Doctors were reluctant to embrace conclusions that implicated the degeneracy of the French nation. In addition, conclusions that discounted the war’s role in the creation of mental illness did not conform to doctors’ own—or anyone’s—experiences. All French men and women knew that no matter how brave they had tried to be in the face of danger and sadness, the war was terrifying, anxiety-provoking, and depression-inducing. Doctors probably revisited their conclusions because they suspected that the constant stresses of a four-year war could have worn away the nerves of any normal, otherwise-healthy individual. Alsatians were especially apt for studying the damaging psychological effects of the war.35 Living in a battle zone that was a primary focus of territorial contention between France and Germany, Alsatians suffered partic­ularly great psychological strains before, during, and after the military conflict. Were Alsatians able to handle those strains without breaking down? Paul Courbon, the asylum director at Stephansfeld (in Alsace), analyzed both the social and psychological effects of the war and the consequent return of Alsace to French control. He found that the social turmoil caused by the war fostered the development of juvenile delinquency in Alsatian children.36 According to Courbon, the war severely disrupted normal family dynamics. When fathers were sent off to war (to fight for Germany), family discipline was

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left to women, who were allegedly unaccustomed to the task and—Courbon implied—ill-equipped to handle it. Without their husbands, women were also forced to assume the role of wage earner. Work took them outside of the home, further upsetting the daily regimen of family life.37 The pillaging of villages during the war and the disorder caused by socialist revolutionaries during the armistice created additional moral and material challenges for civilians. Schools were repeatedly disrupted, leaving children with little daily structure and great opportunities for delinquency. At the same time, wartime and postwar events left unmistakable marks on the minds of many Alsatian adults.38 Courbon found that during the return of Alsace to French control, the deliria of individuals already suffering from mental troubles were frequently colored by current events. Meanwhile, postwar stresses unmasked latent disturbances in seemingly normal individuals. Such was the case for one forty-six-year-old woman who fell ill with anxiety in April 1919. Her condition stemmed from her—completely understandable— concerns over her husband’s professional future. He was a schoolteacher who had been appointed by the Germans before the war, when the region was under German control. The woman feared that he would be replaced as the French gradually took over Alsace, especially since he had favored the Germans. Or, she supposed, he might be sent away to learn French, which she believed would take a long time, since at his age learning a foreign language would be difficult. According to Courbon, the patient’s disturbances lasted for seven months, until she was somehow cured. Despite the apparent importance of situational factors in the development of delinquency and mental illness, Courbon was forced to conclude, like so many of his peers, that the war and the subsequent upheavals should be given only a secondary or “occasional” role when compared to the influence of predisposing factors. The crises faced by the Alsatians might have revealed latent mental troubles, but they had not triggered mental illness in patients who were not already predisposed to it. For years after the armistice, doctors continued to find evidence for the important role of predisposing factors in the genesis of seemingly war-induced diseases. In 1932, a fifty-nine-year-old woman was admitted to Maison-Blanche (a women’s asylum just east of Paris) for emotional troubles related to her son’s death in the war.39 She was diagnosed with chronic hallucinatory psychosis, reactions of the melancholic type, attempts at suicide, and arterial hypertension. She claimed that her problems had begun with news of her son’s death

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more than a decade earlier. She had received confirmation that he was killed in the war, but she refused to believe it. “My son left with his regiment for the war and he has not returned,” she said, careful to use the present tense. “They need him, and they are keeping him. I have waited, and I have not seen anything come back. We supposed that the war was not favorable for us.” Later she began to say that her son had probably married. “I believe that he is living well, married in a good family. . . . He was a good boy.” She even refused to receive the soldier’s pension that was due to her as a parent of a soldier killed in action. Only slowly, over the course of her stay in the asylum, did she begin to accept the truth. She later declared, “They kill love, even maternal love.” 40 Though the woman’s disturbances might seem to have been triggered exclusively by the death of her son, doctors noted that her psychiatric admission in 1932 was in fact her third in twenty-two years. She had been admitted first in 1910 for, among other things, doubts “in relation to her ancestry,” according to the admitting physician.41 In 1913, she was diagnosed with ideas of grandeur and immortality. The loss of her son may have contributed to her recent problems, but it was acting on favorable terrain.

Civilian Accounting Given the conclusions of several medical writers that situational factors and emotional shocks fostered mental disorders mainly in patients with acquired or inherited predispositions to them, it should not be surprising that admissions to mental asylums failed to rise appreciably during the war or even in its immediate aftermath. According to contemporary research, the war did not generate a new population of mentally ill civilians. It primarily drew upon a population that already existed and, in many cases, had already availed itself of psychiatric services. Statistics from the Seine department in fact show that admissions to mental institutions declined during the war, then rose only gradually in the postwar years.42 National statistics (though much more fragmentary) suggest similar trends.43 Whether or not the sadness, stress, or excitement of the conflict triggered mental disturbances, certainly fewer civilians were institutionalized during the war than before. In 1930, the doctors Antony Rodiet and André Fribourg-Blanc presented several explanations for the wartime trough and slow postwar rise in admissions that they found in Paris’s Infirmerie spéciale—one of the city’s two

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major psychiatric admissions portals.44 Their explanations for Parisian trends can be applied to national trends as well. First, wrote Rodiet and FribourgBlanc, many male aliénés left the city for the provinces to escape mobilization and avoid military obligations. Second, the men who were incorporated into the army before displaying their mental disturbances were evaluated at specialized neuropsychiatric or psychiatric centers, or in military hospitals, such as Val-de-Grâce in Paris. Only soldiers with severe, chronic disorders were interned in civilian asylums. Third, the mass exodus of families from cities to the safety of the provinces further reduced the potential population of mentally ill. Contrary to Imianitoff’s hypothesis, Rodiet and Fribourg-Blanc suggested that most families were reluctant to leave family members in institutions during times of crisis. Instead, they kept their troubled relatives at home or brought them along as they fled cities. Fourth, the prohibition of absinthe and other restrictions on alcohol consumption during the war probably reduced the number of cases of alcoholism, which was still treated as a form of mental alienation and typically constituted a large portion of asylum admissions. Rodiet and Fribourg-Blanc were also well aware that, as in past conflicts, the war caused significant administrative disruptions that prevented asylums from functioning normally. Asylums suffered from staff shortages and financial constraints due to the war; some sustained physical damage; and many were forced to convert wards previously reserved for civilian aliénés to military use. In 1924, Rodiet and Fribourg-Blanc sent out a questionnaire to ninety French asylums asking directors to report military and civilian statistics from the war and after the armistice, and also to assess the extent to which the disturbances of interned individuals resulted from the physical or emotional traumas of war. Several directors of provincial asylums responded that their facilities had been too disrupted during the war to keep statistics, and they could not, in the war’s aftermath, spare the manpower to compile them now.45 Dr. Hounard, from the asylum at Armentières, wrote, “The asylum was completely destroyed by the war. All patients and all personnel were, since November 2, 1914, evacuated to different establishments of the interior. From then on, there was no doctor working at the asylum. [I] therefore cannot respond to your questionnaire.” 46 The postwar rise in asylum admissions could be explained by the reversal of the demographic, administrative, and—in the case of alcoholism—behavioral trends that had generated the wartime troughs. Once the war ended, men

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came home from the front, civilians moved back from the provinces, immigrants streamed into France looking for work, alcohol consumption increased, and asylums gradually resumed normal functions. Institutional overcrowding, which had been a problem since the mid-nineteenth century, again plagued French psychiatric institutions after the war. Even if the prevalence of interned citizens did not rise significantly, the total number of patients residing in asylums increased after the war, pushing asylums beyond their capacities. Rodiet and Fribourg-Blanc did not believe that the problem of asylum overcrowding—which they claimed became a crisis again only in the late 1920s— should necessarily be linked to the trauma of war. They suggested that such a correlation was “at odds with the studies, works, and statistics demonstrating that the influence of the war on the mental health of Paris has not been as terrible as the pessimists feared. . . . In general, the social upheaval of 1914–1918 has not diminished the intellectual capital of the greatest city of France.” 47 Rodiet and Fribourg-Blanc were taking issue with psychiatric reformers, including Édouard Toulouse, who, as we will see in Chapter 5, argued that asylum overcrowding was in large part due to the psychological effects of the war. Toulouse and others claimed that this overcrowding could only be relieved by the creation of new psychiatric services that would offer active and early intervention.

War-Induced Melancholy Few doctors publishing research on mental illness trends during or after World War I reported asylum admission rates for specific illnesses (as doctors had after the Franco-Prussian War), but a glimpse at those statistics might help us better appreciate the possible effects of the war on the minds of civilians. A rise in admissions for disorders related to grief, such as melancholy or depression, might suggest that civilians had difficulty recovering from the loss of loved ones. An increase in admissions for mania might suggest that civilians were driven to madness by “patriotic excitation,” as Lunier had argued following the Franco-Prussian War. A rise in alcoholism, meanwhile, might suggest that civilians sought to relieve themselves of consciousness rather than face the horrors of war or its aftermath. Following the Franco-Prussian War, the renowned Paris alienist Valentin Magnan had found that rates of melancholy increased among women admitted to Sainte-Anne asylum.48 According to Magnan, the loss of loved ones,

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unhappiness related to the state of the nation, and heightened anxiety over economic hardships all contributed to the development of these disturbances. If those elements could indeed contribute to the development of melancholy, it would be reasonable to expect an even greater incidence of melancholy during or following the First World War, which was a much longer struggle, with greater loss of life and the potential for greater material privations. Dr. Dupain, the chief doctor of the women’s division at Vaucluse asylum during the First World War, clearly believed that the war generated a larger percentage of sad and depressed patients than was normally found during peacetime. Reflecting on admissions to Vaucluse in 1915, he wrote, “I announce, without it being a surprise, the uncommon proportion of patients afflicted with melancholy or melancholic depression, bouts of which find their origin in present concerns. Almost all these patients have . . . a husband, son, brother, or relative in the armies.” 49 Statistics from the central admissions bureau of Paris asylums do show a rise in the percentage of cases of melancholy among total admissions during the war.50 In 1913, cases of melancholy comprised 13 percent of all admissions, but they accounted for nearly 17 percent of admissions in 1914 and 18 percent in 1915. The percentage hovered between approximately 17 and 18 percent for the rest of the war, only returning to prewar levels in the 1920s. Dr. Dupain attributed the wartime increase in melancholy to current events, yet demographic changes also contributed to the apparent trend. At that time, women were diagnosed with melancholy more frequently than men. When men left for war, the proportion of women admitted to mental asylums rose, as did the proportion of illnesses typically associated with women. The number of women admitted to Paris asylums for melancholy increased from 434 in 1913 to a high of 511 in 1915, but the decrease in admissions for men with melancholy was more dramatic. While 179 men were admitted in 1914, only 79 were admitted in 1917. Did civilians suffer from “patriotic excitation,” as Lunier and Rougé suggested? In 1913, admissions for mania constituted only slightly more than 4 percent of all admissions to Paris asylums. During the war, however, that percentage increased, achieving a high of more than 10 percent in 1916 and remaining above 9 percent for the remainder of the war. The number of men admitted for mania fluctuated from year to year, though the number of women admitted with that diagnosis clearly rose from 1913 through 1916, remaining above prewar levels throughout the war. Were women, then, struck by patriotic excitation or some sort of manic energy related to the war? If so, doctors

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composing statistical reports to Seine department administrators did not find it particularly noteworthy. None commented on the relationship between the war and the increase in admissions due to mania. Admissions statistics for alcohol-related illnesses show the clearest trends. The percentage of admissions for alcohol-related illnesses declined from a high of nearly 14 percent in 1914 to a low of approximately 7 percent in 1918. Admissions rates for alcohol-related illnesses increased again, however, in the 1920s, surpassing prewar levels. According to Rodiet and Fribourg-Blanc, these rates were linked primarily to consumption trends. Prohibitions on alcohol enacted during the war curtailed its consumption, but postwar consumption rose as those restrictions were rescinded. National alcohol consumption statistics for this period support a strong correlation between consumption and alcoholrelated asylum admissions.51 And what about hysteria? During the war, some neurologists claimed to find an epidemic of hysteria among soldiers, but was hysteria as prevalent among civilians during or after the war as it had been among soldiers in wartime trenches? If hysteria was, even among some doctors, still considered a female malady, shouldn’t it have appeared at least as frequently on the home front, where most of the women were? Statistics reported in the Seine department show that admissions to civilian asylums for hysteria remained relatively rare through the first two and a half decades of the twentieth century. Between 1900 and 1925, fewer than 1 percent of all patients admitted to Seine asylums carried the diagnosis of hysteria. Of course, hysteria had always been a relatively rare syndrome among asylum populations. Even during the golden age of hysteria, when Charcot’s influence was at its apex and hysteria was in vogue as a diagnosis, relatively few individuals were admitted to asylums for hysteria. The Salpêtrière, the hospital that Charcot called home, admitted only twenty-one women to its asylum with the diagnosis of hysteria between 1877 and 1880.52 That seemingly small number can be explained in part by the classification of hysteria as a neurological condition. During Charcot’s reign, hysterical patients were often admitted to neurological clinics and hospital wards rather than asylums.53 Even after Charcot’s death, hysteria continued to be seen as a neurological disease—or at least one that primarily affected the nervous system—rather than a form of mental alienation. As we have seen, most battlefield hysterics were treated by neurologists, not psychiatrists. Civilians who were treated for hysteria tended to be seen at neuropsychiatric outpatient services, not asylums. Statistics from outpatient services do show a small rise in cases of hysteria

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during the war. At Sainte-Anne’s outpatient service (which treated neurological, psychiatric, and an array of general medical cases), nearly 7 percent of all neuropsychiatric patients were diagnosed with hysteria in 1913. In 1915, 17 percent of patients carried that diagnosis, though the percentage slipped to around 11 percent for the remainder of the war. Do these statistics suggest an epidemic on par with what doctors found in the trenches? Not at all. Though doctors did conduct twice as many consultations for hysterical patients in 1915 than in 1914, the number remained small: only 76 consultations were conducted for hysterical patients in 1915. And because the doctors who ran the outpatient service did not distinguish first-time consultations with recidivists in reporting yearly statistics, it is impossible to know whether those 76 consultations constituted 76 different people. There was no epidemic of hysteria among civilians in part because there was a lack of incentives for patients to display hysterical symptoms. As many doctors of that era argued, hysterical symptoms served an important function for the wartime soldier: they removed him from harm’s way. Whether he exaggerated or invented symptoms (consciously or unconsciously), the hysterical soldier won a temporary reprieve from battle. Civilians lacked similar motivation. In Charcot’s day, patients might have benefited from the perceived fame of appearing before the great master of hysteria and his bevy of students. But during the war, the prospect of being submitted to extensive neuropsychiatric evaluations and treatments in the neurological wards of wartime hospitals would have provided little conscious or unconscious incentive for French civilians to develop hysterical symptoms. At the same time, doctors lacked the motivation for diagnosing civilians as hysterics. As we have seen, some neurologists used the label of hysteria or “pithiatism” to shame soldiers—it was part of the treatment plan. Doctors wanted to remove all incentives for remaining ill so soldiers could be sent back to duty quickly. Doctors had no equivalent motivation for labeling civilians as hysterics. Once the war ended, the triggering stimuli for hysterical symptoms (among both civilians and soldiers) dissipated. In most of the models of hysteria supported by members of the French neuropsychiatric community, hysterical symptoms were provoked by something—a sudden shock or a suggestion, for example. Hysteria was rarely, if ever, considered a natural degenerative process that appeared in the absence of a stimulus. Whether one followed Babinski’s pithiatic model, which largely equated hysterical symptoms with malingering,

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or one of the other models, which posited that hysterical symptoms were the real results of emotional trauma, he removal of suggestion or the traumatic stimulus should have succeeded in preventing the development of symptoms. The admissions ledgers of the Salpêtrière show that numerous soldiers continued to carry the labels of “pithiatic” and “hysterical” in the years immediately following the war, but—as it was with civilians—the number of hysterics in the military was relatively small compared with the entire population of sick and wounded soldiers.54 Of the 85,616 soldiers of the interior who were hospitalized at some point during 1920 and 1921, only 148 were diagnosed with hysteria.55 These patients constituted 0.17 percent of all hospitalizations and 0.04 percent of all active soldiers. Through the 1920s, the percentage of hysterics compared with all soldiers admitted to a hospital never climbed above 1 percent. Though triggers for mental illness did exist for civilians in the postwar era, they were of a different variety than those that induced hysteria among wartime soldiers. Sadness over personal loss or anxiety over economic troubles were qualitatively different kinds of stimuli than the immediate wartime fear for one’s life. The triggers experienced by civilians in the postwar era more likely caused different illnesses, such as melancholy or anxiety.

Conclusion While some doctors were able to present numerous cases of civilians succumbing to the psychological pressures of life in wartime, researchers nevertheless concluded that there was no appreciable increase in insanity during the war. Or more accurately, fewer individuals sought or were submitted to psychiatric care. These findings, which corroborated similar reports by late nineteenthcentury alienists, led doctors to reevaluate long-held notions about the importance of emotional factors in the etiology of mental illness. Many interwar psychiatrists came to admit that the strong emotions stirred by the war or by subsequent crises triggered mental illness in only a small number of people. A predisposition to mental illness, not situational factors, seemed to predict more accurately who would succumb and who would not. Civilian cases from the war and its immediate aftermath should have helped doctors disentangle the physical and emotional effects of war on French men and women. Because most of the civilians who presented with neuropsychiatric problems had been spared the relentless shell blasts experienced by sol-

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diers, their cases should have enabled doctors to eliminate some of the variables that confused the assessment of military cases and muddied the study of war-induced disturbances. For the most part, however, the discussion of civilian trauma was not integrated with, and was greatly overshadowed by, the discourse of trauma among soldiers. The study of wartime trauma centered on the soldier, not the civilian. That the neuropsychiatric community was more interested in trauma among soldiers should not be too surprising. First of all, the most prominent neurologists and psychiatrists manned specialized centers dedicated to soldiers or the militarized wards of civilian asylums. Doctors studied soldiers because soldiers were their patients. There were simply fewer doctors (and certainly fewer prominent ones) left to study civilians. Second, the study of civilians did not have the same urgency as the study of soldiers. Solving the riddle of traumatized soldiers was a vital national matter. Understanding war-induced illness among civilians was not. Perhaps if there had been an epidemic of functional paralysis among workers in munitions factories, or a plague of hysterical anesthesias among expectant mothers, it would have been a different story. But as it was, civilians who suffered from war-related disorders did not constitute a national crisis that required neurologists and psychiatrists to save the day. Consequently, civilian cases did not offer the same value to doctors who sought to use the material of war to pursue their own professional aims. Because solving the neuropsychiatric crisis among the troops was of great national importance, it enabled doctors to demonstrate their worth. Civilian cases could offer no similar opportunities. It was not until after the war that certain doctors realized that they could use the perception of a civilian crisis to achieve their goals.

President Paul Deschanel (1855–1922), early in his career. Photo used by permission of Roger-Viollet.

Deschanel and his family take a stroll on the grounds of the sanatorium. © L’Illustration.

An advertisement for the suburban sanatorium where Deschanel recovered his health. From L’Informateur des aliénistes et des neurologistes 9:2 (1914).

A soldier diagnosed with mystical delirium. From Antony Rodiet and André FribourgBlanc, La Folie et la guerre 1914–1918 (Paris: Librairie Félix Alcan, 1930).

A soldier diagnosed with acute mania. The original capion read: “I am a Roman emperor!” From Rodiet and Fribourg-Blanc, La Folie et la guerre, 1914–1918.

Joseph Babinski (1857–1932). Photo used by permission of the Wellcome Library, London.

A soldier who developed a functional illness following a thigh wound. The images were taken from a Gaumont film shown at a neurological conference in 1916. From Joseph Babinski and Jules Froment, Hysteria or Pithiatism and Reflex Nervous Disorders in the Neurology of War, trans. by J. D. Rolleston, ed. by E. Farquhar Buzzard, (1917; London: University of London Press, 1918).

A wartime neuropsychiatric center that was created in a former house of detention. From Gustave Roussy and Jules Boisseau, “Un Centre de neurologie et de psychiatrie d’armée,” Paris médical 19 (1916): 14–20.

A soldier with a neurological injury following a shell explosion, before and after treatment. The patient was seen in the service for psychoneuroses at the neurological station of Salins—possibly the same center run by Roussy and Boisseau. I have obscured the soldier’s name in the photographs. © Musée du Service de santé des armées.

Édouard Toulouse (1865–1947). From L’Informateur des aliénistes et des neurologistes 16:1 (1921).

Open psychiatric services in Paris. This photo is used by permission of Roger-Viollet.

Chapter 3 The Politics of Change

B. worked in a

shoe factory in the Creuse before the war.1 He was incorporated with the 90th infantry regiment at Châteauroux in September 1914, but just seventy-seven days later, in late November, he was temporarily discharged for epilepsy. In May 1915, his discharge was renewed by the discharge commission of the Seine department. Under the complicated system of pension rules then in place, B.’s discharge fell under “category number 2”— illnesses not due to service. As such, B. was not entitled to a pension. Though his illness might have restricted his ability to work, the state would not compensate him for his brief service to the nation. His neurological problems were not deemed to be due to a physical wound sustained in battle or an illness contracted while in uniform. To have diagnosed B. with epilepsy might seem to have been a simple task. Before the advent of technologies such as the electroencephalogram (EEG), epilepsy was defined primarily by the occurrence of observable seizures. But in fact distinguishing epilepsy from hysteria required an expert. Charcot had made the distinction nearly a half century before, yet the differential diagnosis continued to prove difficult for practitioners, many of whom simply labeled borderline cases “hystero-epilepsy.” During the war, experts needed not only to determine the correct diagnosis of an afflicted soldier but also to assess whether the reported seizures were real or purposefully concocted to win a reprieve from fighting. If a patient’s neurological condition was real, his doctor then had to decide whether it was somehow triggered by the war. B.’s seizures might have resulted from a head trauma or from a contracted illness. Even if a

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latent condition was merely aggravated by the conditions of war, it might warrant a pension. In B.’s case, however, there was no evidence that the war had anything to do with his problems. And as of 1915, the burden of proof rested with the soldier—or at least his doctor. In the absence of confirmation by a medical authority that a soldier’s condition was caused or aggravated by the war, no pension was awarded. Obtaining that confirmation was not easy. In assembling a discharge dossier, doctors brought together numerous pieces of information, several of which had the power to overturn the patient’s claim. The dossier was supposed to include a report on the soldier’s military service, a copy of the certificate stating the origin of his wound or malady, copies of hospital observation notes, a report on the mental state of the patient during duty, a statement from the gendarmerie in the soldier’s home department about possible hereditary antecedents, and the soldier’s birth certificate.2 The various reports might suggest that a patient had been sick prior to service or that his behavior had been erratic from the first day of military life. Consequently, it was easy for military authorities to reject pension claims. B.’s condition deteriorated following his discharge. Toward the end of 1919, and again in 1920, he was committed to the men’s mental asylum of Bicêtre, located in a Paris suburb. Asylums had long accepted epileptics into their wards, and Bicêtre had a special section dedicated to these patients. The rest of the asylum was filled mainly by men with mental debility, senile dementia, alcoholism, and melancholy. Perhaps not surprisingly, B.’s condition did not improve at Bicêtre. He suffered frequent seizures there. Nevertheless, he was discharged for the second time in the spring of 1920. B. subsequently wrote a letter to the director of the health service of the Paris military government, asking permission to make an appeal before the discharge commission. B. claimed that he was entitled to receive a pension for his condition, since, he argued, it had been aggravated by his military service.3 In June, he was called to the discharge center, where two expert doctors certified that his epilepsy did in fact qualify him for a pension. They awarded him a pension with a rate of 60 percent disability. The medical evaluation had not changed significantly since the initial pronouncement, but the pension law had. The new pension law enacted in 1919 officially removed the burden of proof from the soldier. A great victory

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for wounded and sick soldiers, this change meant that wounds and illnesses were assumed to have been caused or aggravated by the war unless proven otherwise. B.’s case was far from settled, however. In March 1921, it was revisited by the principal physician of the Consultative Medical Commission, an office under the ministry of pensions that had been established during the war to review pension cases. The doctor suspected that B.’s malady had existed prior to his incorporation and that it had not been aggravated by service. He thus asked the gendarmerie of the Seine to collect additional information about the former soldier’s medical and personal history. For a postwar government strapped for money, every pension decision needed to be scrutinized. In May, a captain of the gendarmerie began the inquiry. Had B. suffered nervous crises of any sort before the war? Were they of the same severity as those that were noted after his incorporation? Were there personal or heredity antecedents to B.’s epilepsy that might suggest the war contributed little to his condition? The captain found no incriminating evidence. For example, there were no signs of hereditary predispositions. B.’s father had died “of a chill” (possibly the flu) at forty-six; his mother, at fifty, was still in good health.4 B.’s three sisters, aged twenty-two, seventeen, and fifteen, were also in good health. B. himself had led a normal childhood. He worked regularly as a cutter in a shoe factory and had no history of seizures at work or anywhere else before joining the regiment. Despite the findings of the gendarmerie, the military sub-intendant and chief of the regional section of pensions in Paris sent B.’s dossier to the minister of pensions with the recommendation to reject the pension claim. He concluded that B.’s affliction was not imputable to military service. In September 1922, the ministry agreed with that assessment. According to the decision, B. had spent by far too little time in the military for his condition to have been caused or even aggravated by the war. The ministry noted that B.’s crises had in fact been noticed straightaway, but that it had taken several months to process his discharge. Consequently, there was sufficient reason to reject the pension. B. appealed. In December 1922, the Consultative Medical Commission was asked to review the case again. The commission confirmed that B.’s illness constituted a 60 percent disability and warranted a definitive discharge. But it upheld the pension ministry’s decision: B.’s infirmity was not attributable to military service, and B. should not receive a pension.

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B. appealed again. This time his request was handled by the pension tribunal of Pontoise (northwest of Paris), near where B. had entered a school for professional reeducation. The military sub-intendant close to the tribunal maintained that B.’s claim should be denied. According to this military administrator, B.’s illness had had a slow evolution, and it was neither due to nor aggravated by service. Even though it had taken the army seventy-seven days to discharge him, B. had first been hospitalized only shortly after his incorporation. During his stay in the hospital and during his passage to the discharge depot, B. suffered no excessive fatigues or stresses that could have aggravated his preexisting problem. To confirm the decision, the tribunal decided to order yet another medical evaluation. Charles Vallon, the doctor who later published B.’s case history, was called for that task. Vallon interviewed Henry Wallon, a psychiatrist at the professional reeducation school where B. was receiving training. Wallon noted that B. suffered epileptic seizures at least once per day. The seizures became so problematic that Wallon recommended transferring B. once again to a mental asylum. After consulting with Wallon, Vallon examined B. personally. The doctor noted bite marks on B.’s tongue, which he saw as evidence of epileptic seizures. Vallon further found that B. exhibited a sort of mental fog that was typical of individuals who suffered from frequent seizures. Nevertheless, B. could understand and respond to Vallon’s questions more or less sufficiently. In June 1923, nearly nine years after B. had first been discharged from the army, Vallon composed what would be the final medical word on B.’s case. He wrote that while B.’s testimony about the absence of epileptic symptoms before incorporation was necessarily suspect (since he was a financially interested party in the matter), there was no positive evidence to prove that B. was lying. The gendarmerie’s report stated that no one in his former place of employment saw him having a seizure. In fact, nowhere was there proof that he had suffered from epilepsy prior to his incorporation. More importantly, Vallon had discovered a key piece of information in B.’s history that apparently had remained hidden to the long string of previous investigators. When Vallon asked B. about the events surrounding the development of his malady, B. explained that his first seizure arose unexpectedly in the regiment after reading a letter from home that informed him of his father’s death. Vallon believed that the emotional shock of reading the letter had awakened a disease that had existed in a latent state before B.’s incorpora-

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tion. Vallon thus agreed that the epileptic condition itself was not caused by military service. However, he had to conclude that the condition was in fact aggravated by—or at least during—military service, since there was nothing in the case to overturn the legal presumption of origin. On July 25, 1923, the pension tribunal affirmed Vallon’s decision and at long last awarded B. the pension that he had claimed he deserved.5 At the time, he would have received 1,440 francs per year for a 60 percent invalidity.6 Vallon nonetheless recognized the absurdity of the case. Although he ultimately sided with B. in his appeal for a pension, Vallon found the law unjust in that a patient serving for such a short period in the military could receive a pension equal to that of a soldier who was truly wounded in battle. Over the course of World War I, France mobilized 8.5 million men. Approximately 1.3 million of those men died, and some 3 million suffered illnesses or wounds that necessitated hospitalization. Many of those sick and wounded survivors were unable to return to work after the war. Because they had served their nation and could not resume their normal jobs, they and their families were entitled to monetary compensation from the state. At the time of the armistice in November 1918, however, the French military pension system was a jumble of antiquated laws and multiple, piecemeal revisions that was too complicated to respond efficiently or fairly to the needs of veterans. The pension scheme that faced soldiers was the result of a long history of pension law reform efforts, which had begun soon after the enactment of the original military pension law in 1831. Revisions continued throughout the nineteenth century and accelerated during the First World War. Yet despite the persistence of legislators—and despite their success in making small changes time and time again—it was not until March 1919 that a completely new pension law was finally passed by the French parliament. The pension reform movement successfully overcame the seemingly insurmountable challenges of bringing about legislative change under the Third Republic. Under that weak but long-lived governmental structure, power changed hands frequently. As a result, reform projects that were strongly supported by one government administration could become dead letters when the next took power. Furthermore, the pervasive neglect of political platforms in favor of efforts to secure electoral support meant that there was rarely sufficient agreement among parliamentarians to pass legislation. Efforts to reform the pension law ultimately succeeded first and foremost

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because they had the support of a large, vocal, and highly visible group—veterans. Veterans banded together in associations, and they demanded compensation for their sacrifices. The government did not dare deny former combatants the money they were due. Second, legislators perceived there to be great and urgent need to accelerate the entire discharge and pension process. During the war, wounded and sick men were forced to wait interminable lengths of time for their discharges. This process was unpleasant for soldiers, it clogged hospitals and discharge depots, and it created a backlog of paperwork for administrators. With so many men mobilized, those logjams were no small matter. Once men were discharged, they often waited again for pension disbursements. Finally, the issue of military pensions was closely tied to patriotic sentiment. During and after the war, there was no shortage of national support for veterans. France was determined to make its veterans into heroes. While towns and departments erected monuments to fallen soldiers, legislators— many of whom were veterans themselves—energetically proposed bills to assist France’s heroic combat survivors as they returned to civilian life. Doctors played essential roles in discharge and pension decisions, and they insisted on participating in the efforts to revise the pension law and to create disability tables. During the war, doctors argued that their expert input was vital in helping to construct clearly formulated charts that could assist army physicians in diagnosing soldiers and assessing their degree of invalidity. After the war, they contended that they had important knowledge and wartime experience to contribute to legislative projects. Without question, doctors also saw an opportunity in the revision of pension laws to raise the status of their profession and its individual specialties. They argued that the diagnostic categories, etiological assumptions, and potential for cures that collectively served as the foundation for pension allocations could be determined only by medical experts. The government agreed. It solicited the input of prominent neurologists and psychiatrists during the war to formulate a new disability table. Still, when the new law was finally promulgated, several members of the neuropsychiatric community found it to be highly flawed. The law, and its attached disability table, seemed to ignore their research findings and to challenge their ability to cure patients. Throughout the 1920s, these specialists argued that the law needed serious revision to incorporate advances in neuropsychiatric knowledge and to better reflect their therapeutic abilities.

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The Tangled Web of Pension Laws Soon after the outbreak of the war, the inadequacies of the French military pension system became readily apparent to doctors, politicians, soldiers, and civilians. An accumulation of outdated laws and regulations concerning military pensions yielded a tangled web of contingencies that slowed discharges, delayed the disbursement of pensions, and thoroughly confused soldiers.7 The primary pension law in place had been enacted in 1831.8 Set forth in a time of peace and for a professional army, the law provided a retirement pension [retraite] for officers and under-officers and a permanent leave [congé] for soldiers after their seven-year term of service.9 For officers or soldiers who were unable to complete their term of service due to invalidity (from either illness or injury), the law allowed an anticipated retirement pension, called an invalidity pension. The amount of an invalidity pension depended on the type of invalidity, the number of years served, and the soldier’s rank. According to the law, soldiers of all ranks needed to supply sufficient proof of their infirmity to receive an invalidity pension. The infirmity itself had to meet three criteria. First, it had to be attributable to military service. Preexisting conditions that flared up during service did not qualify men for pensions (although latent constitutional disorders that appeared only after enlisting did qualify). Second, the infirmity had to prevent the soldier from serving. Injuries that opened the right to a pension included blindness or the loss of function of one or more limbs, as by amputation. Third, the infirmity had to be incurable, since all pension decisions were final. Throughout the nineteenth century and after, soldiers often found it difficult to meet all three conditions.10 In the absence of a medical certificate that confirmed the causal relationship between military service and an infirmity, a soldier had to obtain sufficient accounts from eyewitnesses. Especially in times of war, those testimonials were difficult to secure. Thus, the determinations of doctors were often the deciding factors in the issuance of pensions. In cases where sicknesses—and not war wounds—prevented soldiers from serving, there was often a very fine line between preexisting conditions and maladies triggered during service. A doctor might decide that a soldier’s condition predated his military service and deny him a pension. A doctor might also determine that an illness was curable, in which case the soldier would be refused a pension on the grounds that he could eventually return to duty. As if the conditions set forth in the law of 1831 did not already disadvantage most soldiers, an additional condition made it even more challenging for all

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but officers to receive pensions. Under-officers and regular soldiers would only be given an invalidity pension if, having met all three criteria for a pension, they were also unable to earn a living in civilian life. Officers, in contrast, were awarded a pension regardless of their ability to work. Consequently, an officer enjoyed a sufficient retirement plan; a foot soldier received a small pension only if he was left no other options. It became clear to nineteenth-century administrators and legislators that the law of 1831 was, if not unjust, at least inadequate in addressing all of the contingencies of military service and insufficient in meeting changing economic conditions.11 Unable to achieve the consensus necessary to pass a new law, legislators made piecemeal adjustments to the existing law, raising pension rates and offering additional means of compensation for wounded or ill soldiers. For example, in 1814, an ordinance issued by King Louis XVIII had introduced the idea of a “gratification,” or a one-time stipend, for non-­officers who had been discharged but who did not qualify for a full pension.12 In 1853, the minister of war under the Second Empire composed a circular in which he allowed gratifications to be renewed for a second year.13 Following the Crimean War, in 1857, Napoleon III enabled gratifications to be renewed successively by non-officers who had been discharged but who did not qualify for infirmity pensions because they were still able to earn a living.14 Efforts to fix other small pieces of the 1831 law by legislators and government ministers led to additional complications. For example, the laws of June 25 and 26, 1861, redefined the categories of infirmities that qualified soldiers for pensions.15 A ministerial instruction from 1875 distinguished two types of non-pensionable discharges: soldiers discharged for wounds or infirmities due to service (but wounds that did not open the right to a pension) were said to be discharged by category number 1 [réformé no. 1], while soldiers who were discharged with infirmities not related to military service were discharged by category number 2 [réformé no. 2].16 In 1898, legislators created a temporary discharge for soldiers who might sufficiently recover from their injuries or illnesses to serve in the military again.17 A law from 1905 distinguished two different types of temporary discharge, one for wounds or illnesses due to service and another for wounds or illnesses not due to service.18 A decree in February 1906 established three distinct levels of gratifications based on degrees of invalidity.19 To these laws, decrees, and circulars, a long list of others can be added—all of which created a highly confusing system of military pensions.20 The historian Antoine Prost provides a succinct chart of the various types of discharges

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possible at the beginning of World War I, which is reproduced and translated here as Table 1.21 Table 1. The tangled web of pension possibilities Incurable infirmity Unable to earn living Able to earn living Officer Non-officer Curable infirmity

Infirmity due to service

Infirmity not due to service

pension

discharge no. 2

pension discharged definitively no. 1 and gratification

discharge no. 2

temporary discharge no. 2

temporary discharge no. 1

Source: Adapted from Antoine Prost, Les Anciens Combattants et La Société Française 1914– 1939, vol. 1 (Paris: Presses de la Fondation Nationale des Sciences Politiques, 1977), 15.

Not surprisingly, this complicated system greatly slowed the process of discharges and pensions. Wartime administrators were faced with large and growing backlogs of dossiers, and injured and sick soldiers were forced to wait for discharge decisions before returning home. Legislators and government officials quickly realized that the system needed more serious revision.

Wartime Changes and the Role of Doctors Less than a year after the war began, French legislators began a major revision of the 1831 pension law. Anticipating that revising the law would be a long process, the government enacted several stopgap measures in the first part of 1915 that it hoped would ameliorate what had become an unwieldy and largely unfair system. The decree of March 24, 1915, for example, allowed some soldiers discharged by category number 2 to petition to have their disability declared permanent and to receive a full pension. Then, in July 1915, Justin Godart, the newly appointed undersecretary of state for the health service, reorganized the process of discharge.22 He reestablished a Consultative Medical Commission (originally created in the 1880s) to facilitate coordinated, consistent, and rapid decisions. He further instituted a program of medical leaves through which soldiers could return home to wait for a discharge commission’s verdict, instead of clogging up hospitals and discharge depots. Doctors also attempted to alleviate the backlog of soldiers waiting for dis-

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charge and pension decisions. But in many cases, doctors simply sacrificed accuracy in favor of expediency. In unclear cases, they often defaulted to granting temporary discharges or discharges under category number 2. Placing soldiers in these default categories helped to reduce the pile of dossiers waiting for decisions, but it also frequently disadvantaged soldiers. The potential subjectivity of medical assessments, clearly demonstrated by the efforts of wartime doctors to reduce discharge backlogs, had been identified decades earlier. To minimize that subjectivity, nineteenth-century legislators had attempted codify the types of injuries and illnesses that would open the right to a pension. As we have seen, the law of 1831 granted pensions only for severe injuries, including blindness or the absolute loss of use of one or more limbs. Those categories were expanded by the ministers of war and the navy in 1887.23 The échelle de gravité (literally, the “scale of severity”) included six “classes,” or categories, of injuries and illnesses, modeled after categories established for work accidents (see Table 2). Table 2. Classes of injuries and illnesses included in the échelle de gravité of 1887 1st class • blindness 2nd class • amputation of two limbs 3rd class • amputation of one limb 4th class • absolute loss of the use of two limbs • complete hemiplegia; paraplegia • grave alteration of cerebral functions (including loss of memory or speech; imbecility; dementia; mental alienation resulting from wounds of the head, congestion, sunstroke, encephalitis, or fatigues of service) • general paralysis in the periodic state of senility • mutilations extended from the face • [etc.] 5th class • absolute loss of the use of one limb • amputations • partial hemiplegia • progressive general paralysis • progressive locomotor ataxia • epilepsy, chorea, spasms, or other nervous problems resulting from service • [etc.] 6th class • fistulas, tumors, hernias, hemorrhoids, incomplete paralysis • [etc.]

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The scale was meant to take into account the seriousness of each diagnosis, as well as the extent to which each injury or illness would disrupt the soldier’s future career.24 Soldiers who were diagnosed with disabilities in the first five classes (and who met all of the other criteria for a pension) were given a pension in the amount affixed to that class, according to their rank. Officers with diagnoses in the sixth class received an infirmity pension only if they were unable to serve again. Under-officers and infantrymen with diagnoses from the sixth class were pensioned only if they were also unable to earn a living upon their return to civil life.25 That sixth class proved problematic in its application.26 Doctors and administrators often found it difficult to determine whether soldiers would be able to provide for themselves and whether they ultimately would be able to serve in the military again in some capacity. In 1915, military administrators, government officials, and doctors began to revise the categories of infirmity that had been established in 1887. The échelle de gravité, they argued, lacked the precision necessary to be useful for practitioners and to ensure consistency from one doctor to the next. Six categories were simply too few to account adequately for the range of diagnoses assigned to soldiers. Moreover, those categories did not take into account a potential variation in severity within each diagnostic category. To correct these problems, the minister of war, with the assistance of medical and military experts, published a guide-barème—a disability table that was meant to help doctors facilitate diagnostics and enable both doctors and administrators to standardize disability evaluations.27 Organized by diagnosis rather than by class, it fixed a percentage of invalidity for each diagnostic category. For many categories, the guide-barème offered a range of percentages that the deciding doctor could raise or lower, based on the severity of a soldier’s injury or illness. A few samples from the “cranial” section of the 1915 guide-barème (reproduced in Table 3) illustrate the seemingly paradoxical goals of giving doctors some leeway in determining the gravity of an infirmity and making narrow distinctions between similar injuries.28 Table 3. Samples from the “cranial” section of the 1915 guide-barème Injury Scalp injuries with pain or hysterical troubles Loss of part of the skull of 11 cm2 without projection of the dura mater Loss of part of the skull with projection of dura mater

Percentage of invalidity 15 to 30% 20% 30%

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As the excerpts from the échelle de gravité and the guide-barème suggest, the construction of invalidity tables relied heavily on the contributions of medical experts. Defining percentages of invalidity according to specific diagnostic categories demanded specialized medical knowledge, which doctors were keen to demonstrate in an official capacity. First, doctors had to identify the essential diagnostic categories. Second, they had to clearly define the etiology of each illness, since a prerequisite of receiving a pension was a causal connection between the illness and military service. If a soldier’s disease was considered hereditary and not potentially aggravated by military service, the soldier might not receive a pension. Lastly, doctors had to estimate the extent to which a soldier might be disabled by an injury or disease. Even beyond establishing the prognosis and probable evolution of an injury or disease, doctors had to be cognizant of the impact of disease on a soldier’s future professional and social functioning.29 In December 1916, the Neurology Society of Paris held a special conference to help the government assemble a new disability table for what would become the revised pension law.30 Convened at the request of the prominent neurologist Pierre Marie, the conference brought doctors back from their frontline neuropsychiatric centers to submit their informed recommendations. Marie, a member of the Academy of Medicine who would become the next professor of neurology at the Salpêtrière, was part of the government commission charged with revising the guide-barème. Though he was an extremely capable neurologist, clearly able to articulate the latest neuropsychiatric thinking, Marie wanted to hear from all of the best and brightest doctors to ensure that their expert opinions were reflected in the new disability table. Various members of the society would present recommendations for the table, and the society would vote on them. As the conference began, the society’s president asked doctors to temporarily shelve their doctrinal debates so they could focus on the matter at hand. In his presentation to the society, Joseph Babinski once again insisted that pithiatism was nearly the same as malingering and that soldiers with pithiatic disorders should be given few moral, medical, or financial benefits. The society agreed and voted that pithiatic soldiers should not be permanently discharged.31 Once diagnosed as pithiatic, soldiers were to be treated quickly and firmly, and then returned to duty. Leaves for convalescence could be granted, but only on the condition that patients would eventually be returned to the

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same neurological center for another thorough exam. Discharges could also be granted, but only on a temporary basis. Pithiatic soldiers would have to return to duty. If no discharges were allowed for pithiatic soldiers, certainly no pensions would be given to them. When soldiers exhibited pithiatic symptoms along with organic disorders, their pithiatic symptoms were not to be taken into account when determining their degree of disability. Only soldiers who had physiopathic, organic neurological disorders were to receive pensions. André Léri’s report echoed Babinski’s. According to Léri, “War neuroses are almost all hysterical manifestations.” 32 As he had previously reported, Léri claimed that these manifestations accounted for more than 50 percent of all patients sent to neurological centers. He insisted that these disorders were easily cured by “simple and energetic” psychotherapy.33 And because these alleged illnesses were so easily cured, he stated, “We have not therefore occupied ourselves with the rate of invalidities; we fix them uniformly at zero.” 34 Why bother to even discuss pensions when neurotic soldiers would never be discharged or compensated? Joseph Grasset was meant to deliver a third report on neuroses, but he did not attend the meeting; he was mourning the loss of his son, who had been killed in the war. Doctor Villaret thus delivered Grasset’s report. In absentia, Grasset took the opportunity to critique the current process of assigning disability percentages. Doctors were supposed to furnish only clinical infor­ mation about their patients to the discharge commission, which would then render the discharge decision and affix the disability percentage. This procedure had been put in place to help prevent soldiers from reading experts’ opinions before being sent before the discharge commission. But the procedure consequently ignored the role of medical experts. As Grasset stressed, “It has always seemed to us that the specialists, after a long examination of the patient, had more competence than the doctors of the discharge commission to appreciate the case.” 35 Grasset insisted that experts could protect their opinions from their patients’ eyes simply by enclosing them in a sealed envelope. And what should these expert opinions be? Grasset agreed with Babinski and Léri: pithiatics should be neither discharged nor compensated. Soldiers with neurasthenic states or physiopathic troubles that followed traumas, however, could be temporarily discharged with a gratification in proportion to their troubles, or they could be reassigned to the auxiliary services.

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Presenting one of the conference’s two reports on psychoses, Ernest Dupré summarized the conclusions that many psychiatrists reached about the psychological effects of the war: “The war, indeed, has not created new mental affections; but [this] veritable epidemic of trauma, physical and psychic, individual and collective, . . . has multiplied certain morbid forms, lent a special color to the content and expression of certain deliria, [and] . . . revealed . . . certain psychopathic states that were until then latent.” 36 At the same time, Dupré contended that the war alone might trigger illness in some rare cases. Through the etiological trio of physical trauma, physical exhaustion, and infections or intoxications, the war could create mental troubles in previously normal individuals if those elements were particularly violent, extensive, profound, or long-lasting. Otherwise, illnesses would develop only in predisposed individuals. Despite their insistence on the important role of predisposition in the genesis of illness, psychiatrists were nevertheless willing to discharge and compensate some psychologically disturbed soldiers. Patients with acute psychopathologies could be temporarily discharged by category number 2 with a disability range from 10 to 100 percent; those with chronic psychological weakness caused by physical trauma or infection could be discharged by category number 1 with an incapacity from 50 to 100 percent; and soldiers with “chronic post-confusional” psychoses could be permanently discharged with a disability of 20 to 80 percent.37 Men suffering from mania or melancholy would be only temporarily discharged, except in cases where the illness was caused by a physical trauma or a grave infection related to the war; in those cases, the soldier could be discharged with a disability of 10 to 40 percent. Epileptics, such as B., the shoemaker, would be discharged by category number 2, unless a war-induced trauma or infection could be connected to the first bout of illness. In that case, an epileptic would be discharged by category number 1 and rated from 10 to 80 percent disability.

Demands of Veterans and Legislators’ Patriotic Response Despite the revisions legislators made to the military pension system during the war, change did not come fast enough for soldiers, who continued to wait interminable lengths of time for discharge decisions and pension disbursements. Frustrated, many wounded soldiers stuck in hospitals began to band together to form associations for moral support and material assistance.38 Those

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associations multiplied spontaneously throughout France, even among soldiers who had been freed from the limbo of hospitals and discharge depots. Associations focused on the practical concerns of ameliorating discharge procedures and improving pensions. They organized social gatherings for soldiers and established permanent centers to disseminate information about veterans’ rights and pension laws. The historian Antoine Prost contends that veterans’ associations did not make a significant contribution to interwar politics.39 More specifically, veterans neither developed a single political platform nor supported a single party. Even if veterans had wanted to assert themselves in parliament as a single entity, no single political position could have been identified among such a diverse group of French citizens. To the extent that they were united in their ideological outlook, veterans stood for pacifism and strongly opposed the divisiveness of party politics.40 As Prost admits, however, veterans did significantly influence the legislative debates on pension law reform, as well as a myriad of other interwar legislative projects that affected them.41 They did so by presenting a unified front. Efforts at unification among veterans’ associations began in 1917. As parliament prepared to discuss pension law revisions in November of that year, former soldiers and their supporters decided that the time was right to mount a unified campaign in support of pension law reform.42 Until then, veterans’ associations had been highly fragmented; but with the parliamentary debates looming, several veterans’ groups agreed that presenting a single front would strengthen the lobby for legislative change. With the help of the Journal des mutilés et réformés (which published articles and editorials on the prospect of bringing veterans’ associations together), a Paris veterans’ association called the Union nationale des mutilés et réformés summoned members of some of the largest national organizations to the capital for a congress.43 The assembly of veterans formulated its position on pensions through debates led by legal scholars, including Charles Valentino, a doctor of law and medicine. Valentino had published his doctoral dissertation (in law) and a subsequent book in which he argued that the state had a legal obligation to repay soldiers for their military service. Pensions, he wrote, should be inscribed as a “right,” not a gracious gift from the state. He likened military service to the relationship of a worker and employer. Just as employers were responsible for workplace injuries (according to the law of 1898), so should the state be accountable for war injuries.44 After much heated debate, Valentino’s position

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on the right of reparations held sway at the Paris congress. The assembly, momentarily unified, appointed an executive committee to lobby parliament. While some parliamentarians already supported veterans’ right to reparations, the government generally opposed the idea. Pierre Masse, a wounded veteran from Hérault and the reporter from the committee on pensions that reviewed the government’s reform bill in 1916, agreed that the state should give money to severely wounded soldiers out of gratitude, but he absolved the state from legal fault for damages and the obligation of issuing pensions as a right.45 Masse characterized military service (and the injuries that soldiers could receive during it) as an impôt du sang, or “blood tax”—a term that dated back at least to the nineteenth century. According to Masse, military service was a tax that a country’s citizens had to pay. While the payment of money to veterans was reasonable, it need not be considered a right to receive compensation. The strong lobby of veterans’ associations, however, swayed legislators. During the November 1917 discussions in the Chamber of Deputies, Georges Lugol, the reporter for the government’s pension law reform bill, maintained that, in the name of the wounded veterans, the right to a pension must be guaranteed in any new law: “I insist on it because the mutilés . . . have their heart set on this point. . . . I am happy to proclaim, from the height of the tribune, this right recognized by the government and by the commission to the benefit of invalids of all categories.” 46 Henry Chéron, the Senate’s reporter for the bill, similarly mentioned the influence of veterans’ associations when the bill returned to that assembly the following year. “Numerous associations of mutilés . . . have insisted on their desire to see consecrated by the law the right of mutilés and those discharged from the war.” 47 He later added, “The associations have wished that we introduce in the text the formula: ‘Right to reparation for the injury.’” 48 Veterans ultimately succeeded with this demand, as well as a host of others. As of the early 1920s, France was one of only two European nations—the other being Portugal—that included the explicit right to reparation in its pension law.49 In Britain, by comparison, the state provided only meager pensions, forcing veterans to rely on public charity for their means of subsistence.50 The success of French veterans’ associations in influencing legislation should not be surprising. In the first place, many politicians were veterans themselves. There were so many veterans in parliament following the war that the Chamber of Deputies was nicknamed the “Blue Horizon” Chamber after the color of their military uniforms. Furthermore, few politicians would

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have been willing to risk angering veterans in the general population. Ex­servicemen not only constituted a large number of potential votes, they also were important symbols for the French nation. To cross veterans would have been unpatriotic. Patriotic rhetoric was commonly heard in parliament as legislators debated reparations for war victims and pensions for soldiers. In the Chamber of Deputies, Édouard Vaillant, a Socialist deputy from the Seine, made an appeal to his colleagues’ sense of patriotism when he proposed a national insurance system for victims of war in 1915: “Gentlemen, there is not one of us who, each day, upon meeting an old mother or a young wife, an infant in her arms, one grieving her son, the other her husband [who] fell for the country, is not plagued by the same thought: what will become of these women, these children? Will the country saved by these heroic soldiers recognize its debt by saving their family from poverty and the uncertainty of existence?” 51 In the Senate, Henry Chéron argued that legislators had a duty to ease “the poignant sufferings and miseries” of the soldiers who had “saved France” as well as their families.52 He continued, “Who . . . in this country devoted to fraternity and kindness, would tolerate the spectacle of mutilés of war, begging for the benevolence of institutions or persons, the most essential means of existence? Who would tolerate that widows, orphans, who have the right, not only to live, but to live in glory, would be transformed by our indifference, into beggars?” 53 These patriotic expressions, which paid homage to the sacrifices of soldiers and the impact of their struggles on their families, were endorsed by nearly all legislators. Parliamentarians may have butted heads over turns of phrases, legal principles, and specific articles of pension bills, but they repeatedly showed that they were willing to stand above partisanship to bring about change.54 In the Chamber of Deputies, the undersecretary of state in the administration of war, Pierre Léon Abrami, noted that it would be wrong to use pension reform efforts for political gain.55 Louis Puech said that partisanship had no place in the debates, asserting that “France cannot haggle with its heroes who have carried so high and so far the splendor of its name, the price of her safety, [and] the ransom of her glory.” 56 When the bill reached the Senate, Chéron said that it was a “rare privilege” that the Chamber had unanimously supported the bill (after some revisions), and he hoped the Senate could return the favor.57 He was quickly met with applause and shouts of “Très bien!” when he asked, “Is there anything more worthy of arousing the union sacrée, still so necessary as

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the spectacle of bereavements and sufferings by which France, odiously attacked, will have paid her salvation, her glory, and her liberty?” 58

A New Law Enacted On March 31, 1919, after unanimous votes by both the Chamber of Deputies and the Senate, the French parliament finally enacted a law that removed much of the confusion left by the law of 1831 and its subsequent nineteenthand twentieth-century revisions. The new pension law clearly defined which soldiers would receive pensions and how much they would receive; it set forth rules for the distribution of pensions to widows, orphans, and parents; and it included means of appealing and adjusting pension decisions. The law was retroactive, covering all soldiers serving in the First World War as well as all those serving thereafter. Not only did the law simplify the overly complex administration of previous processes, but it also announced a new, supportive, somewhat generous attitude toward veterans. The most important provision of the law of March 31, 1919, was the definitive shift of the burden of proof from the soldier to the state.59 Whereas the law of 1831 required the soldier to prove that his injury was caused by military service, the law of 1919 assumed that such was the case unless proven otherwise by the state. The original precedent for that shift was the law of 1898 about workers’ injuries, in which injuries were assumed to be the responsibility of the employer unless proven otherwise.60 Like a worker, a soldier was assumed to be injured on the job, and the employer (here the state) was responsible for reparations. According to the law of 1919, wounds received during the war and illnesses triggered or aggravated by the “fatigues, dangers, or accidents” of military service were cause for a definitive pension (when the infirmity was incurable) or a temporary pension (when the infirmity might be curable).61 The government had first considered this “presumption of origin” clause three and half years earlier, in November 1915. In fact, on December 9, 1916, the legislature had removed the burden of proof for soldiers who had been discharged by category number 2.62 But the change did not cover all soldiers until 1919. This shift in the burden of proof was a sea change in government thinking on military pensions. It promised to accelerate discharges and help convince veterans that the government was attempting to repay them for their heroic service to France. That sentiment was reinforced by a provision in the law that set forth the right to medical care for all pensioners.63 According to the law, veterans could

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freely choose their own doctors and pharmacists.64 More importantly, all medical and pharmaceutical fees related to military service were to be paid by the state.65 Veterans could select military or civil wards of hospitals in their region, or they could go to private establishments approved by a departmental commission. The state would pay the daily fees of public hospitals; for private establishments, the state would pay the equivalent of the rate of civil wards at the closest public hospital. Even the fees for transporting veterans to hospitals were covered. If their condition rendered them unable to come to a hospital for care, pensioners could receive a special additional allocation to pay for home health care. These provisions were important victories for veterans, whose pensions were generally insufficient to cover extended medical care. They highlighted the complete about-face from the strict requirements of the law of 1831, which often made it impossible for regular soldiers to secure pensions, let alone to pay for medical treatment. The state, it seemed, truly wanted to repay all those who had served and suffered on its behalf. Shortly after the law of 1919 was enacted, legislators released the new disability table.66 As we have seen, the disability table was created by a committee of medical experts who relied on the opinions of doctors in medical specialties to set forth disability rates. The guide-barème of 1919 did not replace the previous tables: war veterans could claim their disability according to the most favorable table, including the 1887, 1915, and 1919 editions. Yet in many cases, the 1919 table offered the most advantageous rates. In the 1919 table, only very small changes were made to the Neurology Society’s recommendations from 1916. For example, the lower end of the disability range for chronic post-confusional psychoses was changed from 20 to 10 percent. Meanwhile, the categories of “chronic psychological weakness” and mania and melancholy were lumped together with other chronic mental illnesses and dementia. According to the guide-barème, “These states cannot, in the present state of science and medically speaking, be linked to military service other than in exceptional cases, where a recent brain trauma or grave infection provoked the appearance of symptoms or . . . if the aggravating influence of military service has been demonstrated by a meticulous investigation.” 67 In those rare cases, patients with such chronic disabilities might be awarded compensation of anywhere from 10 to 100 percent. Just as the Neurology Society recommended, the 1919 guide-barème awarded no money to pithiatics. The French policy of denying pension allowances to soldiers with functional disorders was unique among the major belligerent

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countries. The British, German, and U.S. governments all awarded pensions to their shell-shocked men.68 That generosity, however, was difficult to sustain in the postwar years. Pension requests for war-induced neuroses increased substantially in those countries after the war, as men attempted to realize the financial benefits of having suffered from allegedly war-induced illnesses.69 Governments were hard-pressed to provide adequate medical care for shellshocked veterans, and they struggled to meet the financial burden of paying out so many pensions.70 The hard line established by Babinski and adopted by the French government during the war eliminated the secondary gains for exhibiting pithiatic symptoms and ultimately may have succeeded in minimizing the number of men complaining of hysterical troubles. But while this policy certainly spared the French government from potentially large administrative and financial burdens, it also severely disadvantaged many men who may have truly suffered from the psychological trauma of war.

Pensioning the Disturbed and Patronizing Their Doctors The law of 1919 stipulated that ex-combatants requiring internment in mental asylums would automatically receive 100 percent pensions. This allocation of full pensions for aliénés might appear to be a surprising and generous provision in the law. On closer inspection, however, that was not the case. In the first place, institutional fees were deducted from the pensions of mentally ill veterans. Veterans hospitalized for physical wounds received free care, but mentally alienated veterans—even those whose mental conditions could be attributed to service—did not receive the same benefit. More importantly, the provision that gave institutionalized veterans full pensions actually revealed a long-held prejudice against mental illness. Whereas regular medical patients could recover and return to productive lives, aliénés interned in asylums were generally considered terminal cases. That attitude was underscored by the wording of the law’s pertinent article: the wife of an aliéné was to be given a pension equal to that of a widow.71 Several psychiatrists were incensed by the new law. They believed that their expertise and competence had once again been challenged. The law seemed to ignore their contributions to medical knowledge, including contributions that had resulted from their wartime experiences and medical research. The law also discounted their therapeutic skills. The provision that awarded a full pension to interned aliénés not only portrayed these veterans as incurable, but

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it also suggested that psychiatrists were ineffective at treating them. Throughout the 1920s, these doctors argued for revisions to the pension law and its updated disability table to incorporate more fully their accumulated wisdom and to reflect more accurately their therapeutic abilities. In their critiques of the pension law, these psychiatrists took aim at the “presumption of origin” concept.72 They claimed that by presuming that mental illnesses were due to or aggravated by military service, legislators failed to consider the leading role of predisposing factors. Throughout the war, as we have seen, psychiatrists found that mental problems appeared mainly in people who were in some way predisposed to them. They argued that men with hereditary defects or acquired weaknesses should not be given the same monetary compensation as truly wounded men, even if their mental illnesses only appeared for the first time during the conflict. The doctors also noted that in many cases soldiers were not just predisposed to illnesses, but in fact were already suffering from them. The war simply provided an opportunity for those illnesses to be recognized by medical authorities for the first time. They contended that awarding pensions to mentally retarded men or chronic alcoholics, who often served only briefly before being discharged, was completely unjust. The doctors Henri Colin and Eugène Minkowski, who during the war directed the military wards of Villejuif and Ville-Évrard asylums, respectively, saw numerous injustices of that sort, which were “difficult to pass under silence.” 73 One soldier, M. B., was mobilized in 1918 from a house of correction, where he had been sequestered since the age of fourteen for being a vagabond. Although he never saw military action, he was in the army long enough to be disciplined several times by his commanding officers. His captain, who noted M. B.’s moments of mental absence and his perpetual failure to take responsibility for his actions, ordered an examination for him in a special hospital service. M. B. was first sent to Val-de-Grâce in May 1919, but he was later transferred to the open military ward of Ville-Évrard with a diagnosis of mental debility with “alcoholic support.” 74 Though Colin and Minkowski had little doubt that M. B.’s problems predated his military service, he was awarded a temporary discharge with compensation for a 60 percent invalidity. L. J., another foot soldier, enlisted in April 1918 and left for the front at the end of August.75 He was arrested in December at the Gare de Lyon train station in Paris (presumably after deserting) and sent to Val-de-Grâce. After first being transferred to the military ward of Ville-Évrard, he was shipped to Ville-

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juif in late January 1919 with diagnoses of mania and mental debility. L. J. had bouts of violent agitation in which he yelled and tore sheets. In one delirious state, he claimed that he was a train manufacturer. His admissions certificate to Villejuif called these delusions “polymorphic delirious ideas,” with a predominance of ideas of grandeur.76 L. J. also suffered from auditory hallucinations, illusions, and delirious interpretations. At times he claimed that he was all-knowing and all-powerful, that he was the inventor of bread, and that he was Christopher Columbus. Though Colin and Minkowski believed that L. J.’s problems should not have been attributed to the war, he was nevertheless was given a full pension. Colin and Minkowski contended that these and a bevy of other cases demonstrated the obvious failure of the pension law’s presumption of origin. Those mentally alienated soldiers, whose latent (or manifest) problems unquestionably predated their military service, should not have been given benefits meant for men whose problems were truly caused by the war. The pension law did not need to be overturned, according to Colin and Minkowski, but it did need to be modified to avoid such injustices. Doctor E. Martimor countered that it might be perfectly fair for some soldiers whose symptoms first appeared during military service to benefit from the law’s presumption of origin, especially since the etiology of many psychoses was still unknown (a fact many doctors would have been reluctant to admit).77 Martimor noted that the discipline and close quarters of the army, not to mention the stresses of warfare, could play significant roles in the appearance of disturbances that might previously have been hidden or simply inoffensive. According to Martimor, those wartime factors should not be disregarded in assessing the right to pensions. Still, Martimor agreed that men whose psychoses definitely predated their service should not receive the same benefits as truly wounded men. He stressed that there were mentally deficient men, alcoholics, and soldiers with precocious dementia whose conditions should not be considered to have been caused by the war. Louis Lel . . . , a soldier whose case Martimor reported, appeared to be one such man. Louis, who was twenty-six at the time of Martimor’s writing, was the son of an alcoholic. Martimor described him as an “amoral” retarded person who was unstable, irritable, and impulsive. Since his childhood, Louis had been unruly and violent. In his adolescence, he had committed several criminal offenses (such as stealing and then abandoning a car), which had led to his detention

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in a house of correction. People who knew him before the war had always considered him to have a “weak mind.” 78 He was never able to learn a job. Louis was incorporated in 1916. Soon afterward, he had his first scrapes with military authority. Sent to the war council (the military court) for refusing to obey orders, he was given a year in prison, but with a suspended sentence. At the beginning of 1918, he deserted his unit, was apprehended, and was sent again to the war council. He (or perhaps someone defending him) claimed that a childhood bout of meningitis was the cause of his disobedient behavior. This defense apparently succeeded: the council sent Louis to a mental asylum for observation. He was transferred to a second institution when the first asylum was evacuated following a bombardment. In November 1918, he arrived at a third asylum—this one in his home department—despite having temporarily escaped from nurses during the transfer. He remained there until October 1923, when he was transferred to the hospice directed by Doctor Martimor. As a veteran interned in an asylum, he received a 100 percent pension. Martimor and others argued that only in-depth investigations into patients’ prewar medical and psychiatric histories could shine light on the true origins of their mental illnesses. Psychiatrists seemed to agree that such inquiries would uncover a preponderance of illnesses among soldiers that predated their incorporation into the army. According to Martimor, close to one-third of soldiers discharged for mental disorders were suffering from illnesses whose origins predated the war.79 Opposition to the presumption of origin clause from within the medical community was strong enough that in 1921 the Society of Legal Medicine recommended that it be removed from the pension law, returning the burden of proof to the soldier.80 Given the sentiments of legislators, however, the complete removal of such a central element of the law of 1919 was unlikely. Consequently, psychiatrists argued that, at the very least, the standard for refuting the presumption of the origin of an illness should be less stringent. Ultimately, they contended, the opinion of a psychiatric expert should be sufficient in declaring the cause of an illness to be independent of military service.81 It may appear as if many psychiatrists’ central goal was to suppress the pension rights of psychiatric patients, but that was not at all the case. In fact, some psychiatrists believed that those rights should be expanded for certain patients. For example, the alienist Pierre Beaussart argued that the six-month statute of limitations set for pension claims due to mental illness was too short.82 Re-

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calling the conclusions of Cygielstrejch’s 1912 study on illnesses among Russians, Beaussart maintained that some mental disturbances had long latency periods. Whereas some illnesses triggered by the war might appear immediately, others might develop only years later. Consequently, patients should be allowed to request a medical evaluation for the right to a pension after the six months following their discharge.83 The calls to change the pension law are better viewed as attempts to reassert the medical competence of psychiatrists and to revive their specialty’s legitimacy in the eyes of administrators, politicians, and the public. The presumption of the origin of illnesses, doctors claimed, had obviated much of the need for their expert psychiatric opinions. Moreover, it ignored important currents in psychiatric thinking. Legislators had neglected psychiatrists’ opinions as to the causal connections (or, more accurately, the lack of connections) between wartime shocks and the development of mental illness. By arguing for the modification of the provision for presumption of origin, at least for psychiatric cases, psychiatrists hoped to reestablish themselves as key contributors to the decision-making process. Psychiatrists continued the struggle to assert their expertise by critiquing the article of the 1919 law that awarded interned aliénés full pensions. In their arguments against this provision, psychiatrists noted that legislators had failed to take into account the range of disorders for which individuals were admitted to mental asylums, the potential curability of many illnesses, and the possibility for the abuse of this provision by families of mentally disabled soldiers. Legislators might have envisioned the provision as a generous allotment for soldiers either psychologically traumatized by the war or inappropriately incorporated in the first place. But psychiatrists, who for decades had been attempting to raise the professional status of psychiatry, saw an old prejudice in this clause that belittled aliénés and more importantly, challenged the effectiveness of psychiatric treatment. According to psychiatrists, legislators had mistakenly assumed that asylum commitment was reserved only for patients with the most grave mental illnesses.84 Yet not all interned individuals suffered from severe, chronic conditions. Before the multiplication of outpatient services, internment was simply the most widely available mode of psychiatric treatment for all psychiatric conditions, even very mild ones. The severity of illness alone did not determine whether or not a person was interned. Psychiatrists also asserted that legislators had failed to realize that intern-

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ment was generally a solution only for those patients who lacked adequate home care. Well aware of the poor conditions in asylums, families often kept their mentally disabled relatives at home. The law of 1919, argued psychiatrists, was unjust in that it would provide a 100 percent pension for an interned aliéné, no matter what his illness, and a lesser pension for an aliéné who could be cared for by his family.85 According to psychiatrists, legislators also assumed that internment, or the illness that triggered internment, was often a permanent condition. Legislators retained the old idea that the interned aliéné was forever lost to society; the best the state could do was to offer a charitable compensation to him and his family. To highlight those legislative assumptions, psychiatrists pointed to the language of the law, which, as was noted earlier, specified that the wife of an aliéné was to be given a pension equal to that of a widow.86 This notion—that an aliéné was condemned to be forever insane—struck a particularly dissonant note with psychiatrists. These doctors argued that they were no longer mere asylum keepers, watching over the poor and the wretched. They were medical men who actively treated their patients and ameliorated their conditions. Psychiatrists contended that pension rates for mental illnesses should be gauged by the percentage of disability, not determined by the fact of institutionalization. Psychiatrists also believed that the law of 1919 lent itself to potential abuse by scheming soldiers or their families. As psychiatrists noted, a man could, according to the law, be declared fit for service, demonstrate signs of mental illness within a few days of incorporation, be sent to an asylum, and receive a full pension, which might not only cover asylum fees but also provide a small income to the pensioner’s family. Some families might even voluntarily commit veterans who could have received adequate care at home, just to receive that part of the pension.87 These types of potential injustices led psychiatrists not only to criticize the law of 1919 but also to reevaluate the process of military incorporation. The army was plagued with psychiatric casualties, according to psychiatrists, because it had admitted too many men who were predisposed to psychiatric illness. In an effort to declare as many men as possible fit for service, the army had neglected to conduct careful psychiatric screenings.88 Some psychiatrists argued that the state did owe a pension to mentally unsound soldiers who were unjustly incorporated, since the men and their families might be financially disadvantaged by incorporation and after all, the state only had itself to

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blame for the error. Still, doctors insisted that the law should not award the same material and moral advantages to mentally deficient men as to men who were fit, had served, and were injured while defending their country.

Updates and Revisions In theory, the law of 1919 was a great step forward for veterans. The application of the law, however, was still too slow for many men. At the end of 1919, public administrators trying to disburse pensions were still overwhelmed, and veterans were still frustrated.89 In an attempt to ameliorate the situation, the government created the post of minister of pensions to coordinate under one office previously disparate organizations and services.90 Parliament also began to pass slight modifications to the law of 1919 to accommodate the demands of veterans. It also increased pension payments in order to compensate for the rising costs of living. The table of disabilities attached to the military pension law was also modified numerous times during the interwar period. The decree that accompanied the 1919 table specified that the guide-barème was meant to keep pace with the latest advances in medical science. Over the years, medical specialties adjusted diagnostic categories, etiological assessments, and percentages of disability attributed to various diseases and injuries. In 1929, the neuropsychiatric community had its opportunity to make changes to the guide-barème. A committee of neurologists and psychiatrists that included Henri Claude, Maxime LaignelLavastine, Angelo Hesnard, Roger Dupouy, Jean Lépine, André Léri, and Octave Crouzon, among others, amended—and greatly extended—the section on neurological and psychiatric disorders to reflect more accurately the current knowledge and skills of the neuropsychiatric community.91 The 1929 update continued to reflect Babinski’s influence on neurological thought. The committee used the term “pithiatism” (alongside “hysteria”) and generally adhered to Babinski’s principle of depriving pithiatics of material benefits. According to the table, patients with pure pithiatism would not earn a pension. And for the most part, patients who developed pithiatic symptoms on top of true, organic illnesses would not receive additional benefits for the exaggeration and prolongation of their illnesses. Still, the 1929 committee seemed willing to give pithiatics a morsel: “In absolutely exceptional cases where hysteria seems . . . indisputably to aggravate the clinical picture, there would be . . . grounds to raise slightly the invalidity (by 10 percent for exam-

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ple).” 92 This postwar collection of experts, more detached from the urgency of a nation at war, at least considered the possibility that pithiatism or hysteria might, in some rare cases, be more than simply a disciplinary problem. The section on mental illnesses meanwhile attempted to address some of the problems created by the 1919 law’s provision on presumption of origin. According to psychiatrists, the 1919 law had failed to underscore the important differences between constitutional illnesses (which comprised most cases) and those rare disorders that were truly caused or aggravated by the war. As a result, too many soldiers were assumed to have illnesses that were attributable to service. Psychiatrists claimed that their wartime experiences and research proved that a large proportion of mentally disturbed soldiers were predisposed to illness and, more importantly, had suffered bouts of illness prior to incor­ poration. Thus in the 1929 table, psychiatrists explicitly stated that distinguishing between constitutional illnesses and truly war-induced illnesses was essential in making accurate pension assessments.93 Furthermore, doctors once again insisted that most categories of mental illnesses could not be attributable to military service. Just as they had stated in 1919, doctors argued that disorders such as mania and melancholy were essentially of a constitutional nature. The constitutional nature of illnesses would become clear to doctors if they could attain access to information about the patient’s experiences before incorporation: in many cases, men afflicted with mania, melancholy, or other disorders had exhibited problems previously. Still, the 1929 committee remained willing to grant some pensions to mentally disturbed soldiers if their conditions were somehow linked to duty. In the case of periodic or intermittent psychoses (such as mania, melancholy, or manic­depression), a patient might be awarded a pension after a sufficient observation by an expert in an appropriate medical establishment. Whereas the 1919 table included very few psychiatric disease categories, the 1929 version contained numerous diagnoses and a variety of options for disability percentages, according to the intensity of the illness and the degree to which it affected social functioning. For example, patients with obsessive, phobic, anxious, or emotive states whose social adaptation was only moderately affected could be granted a 20 to 40 percent disability pension. Patients might be awarded disability pensions of 60 to 80 percent for illnesses that caused a complete disruption of social adaptation. Illnesses that necessitated internment garnered a full pension. Doctors, then, did not remove the allotment of full pensions to soldiers who

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required asylum commitment. But they did attempt to eliminate the perceptions that aliénés were completely lost to society. In the lengthy descriptions of illnesses, their causes, and their typical progressions in the 1929 table, doctors asserted that not all mental disorders affected patients continuously. Bouts of mania, melancholy, and manic-depression, for example, might leave patients healthy for six or more months per year. As the table showed, these patients might suffer from only minor disruptions in social functioning. The changes made to the guide-barème in 1929 do not add up to much in terms of soldiers’ care and quality of life. But the way in which changes were presented reflects neurologists’ and psychiatrists’ continued attempts to demonstrate their specialized medical knowledge. Compared with the skeletal disability table from 1919, the 1929 revision reads like a textbook, with long definitions of disease categories and discussions of important etiological distinctions. Meanwhile, the inclusion of far more illnesses, and more levels of invalidity, served to showcase doctors’ ability to distinguish subtle variations in mental disturbances. Finally, the repeated use of the term “expert” throughout the text serves as a not-so-subtle reminder that only specialists were qualified to render pension decisions.

Conclusion Though legislators had struggled for decades to overcome the torpor of the Third Republic to revise the pension law, the war served as a powerful catalyst. It created a crisis of pension disbursement that demanded swift fixes, and it brought together a large, powerful, and vocal lobby of veterans who insisted that their sacrifices for the nation be recognized. Pension law reform was a national cause that affected millions of men and women, and no legislator could afford to ignore it. Revision of the pension law thus became a high legislative priority. As one deputy declared during the war, “The question of military pensions is without any doubt one of the most important and the most serious that can solicit the attention of the Chamber.” 94 Throughout the war and after it, doctors inserted themselves into the processes of legislating and administering military pensions. Neurologists and psychiatrists claimed that only they could determine whether an injury or illnesses was due to military service, whether it was curable, and how much of a pension an afflicted soldier should receive. These doctors not only contributed to legislative debates, but they also drafted guides to assist practitioners and to establish degrees of invalidity that were based on the most current medical

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knowledge. By asserting their expertise, these doctors hoped to raise the status of their specialties. Unquestionably, the pension decisions made by neurologists and psychiatrists, and the laws and disability tables enacted by legislators with the help of those doctors, had significant consequences for tens of thousands of men and their families. The difference between one diagnosis and another, and the change in one paragraph of one law, could be measured in francs. The next chapter shows how decisions made by doctors and legislators compounded the challenges facing traumatized men and their families after the war. It also traces the long and difficult struggle by the psychologically traumatized and their families to alter the pension law.

Chapter 4 Les morts vivants If there is one category of mutilés worthy of interest and for which one has never done anything, it is that of the interned from the war, restored to their profession and supposedly cured. As if one could cure nervous illnesses? . . . It will always remain this tunic of Nessus: “He was crazy and locked up.”

For many French soldiers

who exhibited neuropsychiatric symptoms during the First World War, the armistice meant little. Those with severe psychiatric problems remained in the mental asylums where they had been deposited over the course of the conflict. Approximately four thousand such men resided in departmental institutions through the mid-1920s.1 Despite gradual improvements in pension allocations throughout the interwar period, the level of care that institutionalized veterans could afford—and for which they themselves were required to pay, out of their pensions—was poor. Married patients suffered more: after asylum fees were deducted from their pensions, more money was deducted to provide for their wives and children. Whatever remained—which was little to nothing—was to be used to improve the level of soldiers’ institutional care. Shuffled from cities to the provinces as administrators reorganized services to reduce overcrowding and cut costs, and often neglected (along with asylums’ permanent, chronic clientele), many interned veterans felt abandoned by their families and their country. The fortunate few who were supposedly cured and then released attempted to resume their civilian lives with meager pensions and the social stigma of having been interned. That stigma felt like the “tunic of Nessus”—the poi-

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soned shirt that killed Hercules. As E. B., the dentist who wrote the passage above, complained, “Colleagues do not wish you harm, but they talk about it behind your back; neighbors whisper about it; they pity you, they avoid you, and from this quarantine is born a vicious circle from which the ex-interned cannot leave. This degradation wakes his pathological state and increases the mistrust of his circle of friends and family.” 2 If and when those former soldiers were once again overcome with psychological troubles, they received no special privileges as veterans. Without institutions designated for the psychiatric casualties of war, their options were the same as their civilian peers: private care for the rich or public institutions for everyone else. The postwar plight of veterans who developed war-related psychological problems was thus bleak. They had few institutional options for treatment and hardly any power to control their own fate. The pension law of 1919, which was meant to provide wounded veterans the right to financial compensation for their service to the nation, did little for the psychologically traumatized. Men committed to mental asylums were given full pensions, but those allocations barely covered institutional fees, let alone their families’ living expenses. Several doctors, legislators, and members of prominent veterans’ associations spoke out in support of psychologically traumatized veterans. They fought to revise the pension law in order to ameliorate the plight of institutionalized veterans and their families. As much as possible, these advocates pushed their demands into national forums: they frequently published articles, for example, in the most prominent publication for wounded veterans. Their pleas even occasionally reached the floor of parliament, where legislators seemed to respond with the same sort of patriotic rhetoric produced in support of wartime projects for pension law reform. Yet advocates for mentally ill veterans could not produce the same results as advocates for the physically wounded. Collectively, the insane and their supporters did not represent a large number of votes. As a result, they could not hope to command the attention of politicians. Moreover, mental illness was still too closely tied to degenerates and drunks. While an amputee could easily be touted as a hero, a chronically confused soldier was not a model veteran. Try as they might, advocates for mentally alienated veterans could never convince legislators that the insane were as worthy of assistance or as valuable politically as the physically wounded. Changes did come, but they came too slowly and were too small to effect any real improvement in the lives of aliénés or their families.

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The mentally alienated veterans sequestered in asylums were considered les morts vivants—“the living dead.” They were survivors of the war, but they were as good as dead to their families, who saw them rarely and could no longer count on them for financial or emotional support. That term—“the living dead”—can be applied just as easily to a large number of other psychologically traumatized French men and women, both within and outside asylums. Even those who escaped institutionalization were seen to inhabit a realm that was somewhere short of truly living. The stories of the institutionalized “living dead” highlight the political, social, and economic challenges faced by psychologically traumatized veterans and their families. These stories also illustrate how deeply medical decisions affected the lives of thousands of individuals. Furthermore, they show (once again) how tightly intertwined were the narratives of psychologically troubled veterans and the efforts of psychiatrists hoping to bolster the status of their specialty.

Institutional Options By the time of the armistice in 1918, well over 2 million wounded and sick soldiers had passed through French medical institutions. Val-de-Grâce, Paris’s military hospital since the late eighteenth century, received a large number of those men during the First World War, including twenty-five thousand soldiers with psychiatric disturbances.3 Doctors at Val-de-Grâce examined, diagnosed, and treated those men and then sent them back to their units, interned them in civilian asylums, or sent them to prison. While Val-de-Grâce processed a large number of patients, neither that institution nor other military hospitals in France could care for all the soldiers who required care during wartime. From the beginning of the war, military administrators requisitioned civilian hospitals for the treatment of soldiers with all types of injuries and illnesses.4 Insane asylums and civilian hospital wards that had previously been reserved for neurological or psychiatric patients were also requisitioned for military use.5 The Salpêtrière, for example, still at the time a renowned center for neurology, received numerous soldiers attacked with nervous affections.6 Meanwhile, at Maison-Blanche—a women’s asylum in peacetime—doctors created an open neuropsychiatric service to receive soldiers who exhibited mild neuropsychiatric disturbances after sustaining head wounds.7 Mentally alienated soldiers were sent to the Seine asylums of Ville-Évrard and Villejuif.

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Just as civilian hospitals were forced to adapt in order to accommodate the relentless waves of wounded soldiers, so too were military institutions. Les Invalides, the grand French institution that was designed during the reign of Louis XIV as a retirement home for old soldiers, began to accept a number of wounded, recently discharged soldiers during the war.8 In addition to admitting pensioners who could not receive the treatment that they needed from their families and retired soldiers who warranted special care, Les Invalides took in severely wounded soldiers who required prolonged treatment or assistance for the “usual acts of life.” 9 Because of the limited number of places available at Les Invalides, administrators enforced strict admissions standards. Only men with an invalidity of 80 percent or greater were admitted.10 Each soldier also had to request admission specially from the minister of war through the regional director of the health service, who was charged with assembling applicants’ dossiers. Once admitted, wounded men were subjected to the same rules that governed the hierarchy and discipline of the army. They wore military uniforms and maintained their rank from the time of their discharge. Soldiers paid the hospitalization fees out of their pension. By 1920, civilian hospitals and hospices in and around Paris had treated more than 106,000 military men in their wards in addition to thousands more in mental asylums.11 Many military wards remained open years after hostilities ended. The Pitié, Necker, Saint-Antoine, Laënnec, Hôtel-Dieu, and the Salpêtrière continued to treat soldiers into 1920. Les Invalides continued to treat recently wounded soldiers until September of that year, when a governmental decree returned the institution to its charter of catering mainly to old veterans.12 In France, there was no permanent institution or system of specialized hospitals for veterans with psychiatric disorders. Depending on their diagnoses, soldiers with psychiatric problems were either treated in military hospitals (such as Val-de-Grâce), sent to general medical civilian hospitals that had wards for head wounds (such as Maison-Blanche), released from care (if they had been “cured”), or sequestered in public asylums. The asylum was, of course, the most deplorable of those options. Not surprisingly, the idea that veterans—the heroes of France—might be forced to share close quarters with ordinary degenerates and noisy drunks in public asylums was troubling to the advocates for mentally ill ex-combatants. Consequently, after the war, some of those supporters proposed establishing a national institution, or a system of institutions, for the country’s psychologically troubled heroes. This national institution would not be obligatory, but

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rather a dignified option that would spare former soldiers from the shame and unpleasantness of public asylums while offering them the emotional support of their fellow soldiers. These hospitals, said one advocate, would be places “where the abandoned would find a new family.” 13 The doctors Rodiet and Fribourg-Blanc strongly endorsed the idea of surrounding veterans with family, even if the family was not their own. They recommended placing some troubled veterans in familial colonies or with individual families—two options that had benefited mentally ill civilians for decades.14 While some asylum doctors were willing to release veterans to their own families or friends as their conditions improved, they were reluctant to discharge men lacking relatives or outside contacts. Placing these men in familial colonies or in the homes of willing families would provide veterans with opportunities for work that could help them avoid relapses. At the same time, these types of placements would enable doctors to maintain some degree of medical surveillance over their ex-patients. Proposals to place mentally troubled veterans outside of asylums and to create a system of institutions specifically designed for them were not unique to France. In the United States, for example, mental hygienists worked with the American Legion (the large, national veterans’ organization founded in 1919) to lobby for new veterans’ facilities during the early 1920s.15 Thomas Salmon, a mental hygienist and military doctor during World War I, played a key role in those efforts. He strove to demolish the stereotype of shell-shocked veterans as shirkers—an image reinforced in France by Babinski’s model of pithiatism. With Salmon’s help, the American Legion convinced the U.S. Congress to pass large appropriations bills in 1921 and 1922 to build new hospitals and to organize a system of outpatient services for veterans. Political haggling, however, delayed the release of money.16 In France, a chronic shortage of funds and the repeated failure of politicians to muster sufficient legislative support prevented the creation of new national institutions designated for psychiatrically disabled soldiers. By the early 1920s, though, many such former soldiers had already collected at another “national” institution, just outside of Paris: Charenton–Saint-Maurice.

Aliénés or Expectant Mothers Located in Neuilly-sur-Marne, Charenton (as it was originally called) was a large hospice built in the seventeenth century by the Brothers Saint-Jean-deDieu.17 The institution, whose name would come to evoke hellish images of

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madness, was one of the first institutions in France created for people with mental disorders. Closed during the Revolution, Charenton was reopened during Napoleon’s reign, when Bonaparte placed the facility under the direct administration of the French government. Hence Charenton was a “national” institution—the only national institution for the mentally ill. Today, it is probably best remembered as the institution where the Marquis de Sade was sequestered in the early 1800s. It subsequently became the setting for the 1963 play by Peter Weiss, Marat/Sade. In 1920, the institution—frequently called Saint-Maurice in that era— housed 118 veterans with psychiatric problems. Though Saint-Maurice served an important purpose for these mentally alienated veterans, government administrators decided that another, more pressing issue demanded the replacement of those men with a completely different type of patient—unwed expectant and nursing mothers. The protection of natality, government officials argued, was far more important than the kind care of aliénés. Primarily on the advice of Adolphe Pinard, a professor of obstetrics and a parliament deputy, the French government planned to transform Saint-Maurice into a maternity, or “lying-in,” hospital. Psychiatrists believed that the value of their specialty was challenged. They were outraged by the plan, and they held a special meeting of all psychiatric societies and professional associations at the Sainte-Anne asylum on June 21, 1920, to formalize their protest.18 As part of their long list of objections, they argued that transforming Saint-Maurice would be contrary to the interests of current patients, many of whom were veterans. The institution, they said, had long catered to functionaries and soldiers. In fact, according to psychiatrists, it was designed to receive the mental invalids of war. Despite its age, SaintMaurice was still one of the most well-adapted facilities for these men: the way the wards were divided made it easy to group and isolate patients according to their respective conditions. Converting Saint-Maurice would be impractical, argued psychiatrists, since the facilities were not set up to accommodate expectant and nursing mothers. Furthermore, it would serve to destroy a model psychiatric institution with a grand tradition. Some of France’s premier psychiatrists had worked at SaintMaurice, including J. E. D. Esquirol and Antoine Laurent Jessé Bayle, who discovered the anatomical underpinning of general paralysis. In addition, removing psychiatric patients from Saint-Maurice would result in the elimination of jobs for alienists. Finally, objected psychiatrists, the proposition to transform Saint-Maurice demonstrated the ongoing prejudice that madness

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was incurable—a myth that the experience of war surely had dispelled. As one doctor argued, “The war, by multiplying the cases of curable psychopathy, has shown that subjects affected by acute psychosis are curable in the same degree as other patients, and—more completely still than tuberculosis cases, for example—can be rehabilitated and can resume completely productive activity.” 19 Psychiatrists took their protest directly to the French government, sending a delegation to meet with the minister of hygiene, Jules-Louis Breton, on July 1, 1920.20 The delegation, which included prominent doctors such as André Antheaume, Henri Colin, and Édouard Toulouse, assured Breton that they were in favor of protecting natality and enhancing medical assistance to pregnant women, but that they remained strongly opposed to this specific plan. They noted that the proposal to transfer current patients from Saint-Maurice to provincial asylums would be particularly damaging to the patients’ health, since the only consolation for many of them was visits from their families. Breton seemed willing to compromise. He proposed allowing the current population of aliénés to remain temporarily in a special wing of the establishment. The delegation left contented, but Breton reneged on his promise just a few days later. On July 31, 1920, parliament passed a law that officially transformed the national maison de santé of Saint-Maurice into a “national house of maternity.” 21 Psychiatrists and advocates for veterans’ rights did not give up the fight. In medical journals, veterans’ newspapers, and the popular press, they insisted that the transformation of Saint-Maurice was a bad decision.22 Georges Leredu, the new minister of hygiene in 1921, heard the protests and granted the asylum a partial reprieve.23 He pronounced that the asylum would coexist with the maternity facility and that recruitment of patients would begin again. Neither psychiatrists nor veterans’ advocates were satisfied, however. SaintMaurice’s chief director was Adolphe Pinard, an obstetrician, and its official title remained the “national house of maternity.” Furthermore, Pinard repeatedly insisted in public that Saint-Maurice was exclusively a maternity institution. According to Georges Laûx, a staunch advocate of veterans’ rights, Pinard planned to co-opt the budget that had been previously allotted for Saint-­Maurice, even though the money had been proposed by the minister of pensions for the care of veterans.24 Ultimately, Laûx wrote, Pinard intended to transfer the aliénés of Saint-Maurice to the provinces. For psychiatrists, the plan to transfer alienated veterans from Saint-­Maurice was yet another professional defeat in a long string of others. For the families of interned veterans and their advocates, however, the battle was not quite

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finished. They sent a stream of protests to the government. Nevertheless, a government commission upheld Pinard’s plans on the grounds that asylum care was less expensive in the provinces and overcrowding was less severe.25 The commission concluded that transfers were in the best interest of patients. Transferred veterans would spend less of their pensions on asylum fees and would potentially have better treatment in less-crowded facilities. Veterans’ advocates refuted those claims. First, they insisted, the quality of care was better in the Seine department, which attracted the best doctors in France. Second, the prospect of paying less would mean little to families of aliénés if their fathers, sons, and husbands received inferior care or were farther away from home. Families protested, furthermore, that transfers were being undertaken without their consent. The demands of Madame J., for example, the wife of an aliéné interned at Saint-Maurice, were rebuffed by administrators.26 When she first received a letter informing her that her husband was to be transferred from SaintMaurice to a provincial asylum, she replied that she did not approve of the transfer. Although Madame J. lived in the provinces, she wanted her husband to remain at Saint-Maurice because she believed that he would receive better care there. Trying to dissuade her, Dr. A. Paloque, who worked in the ministry of pensions, wrote in response: I have the honor of making it known to you that, conforming to the prescriptions of the circular of the Minister of the Interior, which stipulates that there is reason to hospitalize an aliéné in an asylum situated in proximity to the residence of his family, I have the intention of transferring to the asylum of C . . . , Mr. André J., presently interned at the National House of Health of Saint-Maurice (Seine). Moreover, the price per day at said establishment [Saint-Maurice] absorbs the totality of the patient’s pension of invalidity, whereas at the asylum of C., the price of 7 francs 50 per day would allow the constitution of a remainder [pécule] of which a part would be used to improve his regime during his stay at the asylum, the other part being given to him upon his release. Consequently, I would like you to let me know quickly, if you have any objections . . . about said transfer.27 Madame J. did object. To bolster her position, Laûx presented her case publicly in the Journal des mutilés et réformés, the most prominent veterans’ journal. When Paloque saw his letter reprinted in the Journal, he apparently reassured

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Laûx and Madame J. that André J. would not be transferred without his wife’s consent.28 Still, forceful letters to the J. family continued to come. According to Laûx, Paloque broke his promises, succinctly concluding one letter to Madame J., “You will be advised by…the director of the asylum the date of this transfer.” 29 According to Laûx, other examples of forced transfers were easy to find. One family received a letter from Saint-Maurice stipulating that “because of the overcrowding of the asylums of the Seine, it is not possible to give satisfaction to the present demand [to keep the patient there].” 3 0 Laûx believed that claim to be pure fiction. There were four hundred free spaces at Saint-Maurice.

Wives The refusal of administrators to heed the wishes of alienated veterans’ wives was only one of many legal, economic, and emotional blows suffered by the families of aliénés. First and foremost, those families lost loved ones to madness. Predisposed to mental problems or not, many soldiers developed mental illness only during the First World War. Having left their homes in apparently good mental health, these men came back “human wrecks,” unable to cope with normal life. Though some ultimately recovered, many did not. Whether cared for at home, sent to private establishments for rest cures, or sequestered in asylums, many men never regained their mental vitality. Once the heads of households, they now required more emotional and financial support from their families than they were able to give in return. The families of men who were interned in asylums during and after the war suffered additional blows. The social scar of internment was meted out on the afflicted veteran’s family, especially in smaller towns and villages, where everyone knew their neighbors’ business. Institutionalization also brought many practical challenges. First, the absence of the primary wage-earner, particularly in rough economic times, was financially devastating to families. The pensions that wives received as compensation for their interned men were totally inadequate to support their families. Second, the physical distance between many families and their interned loved ones made it impossible to sustain meaningful relationships. Even when interned soldiers were deposited in the asylums of their home department, they were not guaranteed to be within close proximity of their families. Forced transfers left many aliénés more than one department away from home. The relatives of mentally alienated veterans

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felt as if they had lost their loved ones several times over—first to war, then to insanity, then again to a distant asylum. Meanwhile, former combatants no doubt felt abandoned, not only by their families, but also by their country, which seemed to care little for their plight. The reality was that the postwar economic situation was as much to blame as politics for the abandonment of veterans. Parliament was unable to raise pension allowances for veterans fast enough to keep up with the rising cost of living. Consequently, the wives of physically and mentally wounded men were forced to work, leaving them little time to visit their husbands in hospitals and mental asylums. Even for those who had time to spare, the cost of transportation to and from mental institutions restricted the frequency of visits. As one frustrated wife wrote to Laûx, “What hurts me, is when they say that families abandon their sick ones [malades]. It is true that visits are more rare; . . . at the beginning of my husband’s internment, I was paying 2 francs 60 for the train, so I could go there very often. Today, with my daughter, I must pay 21 francs 40; so I cannot go to see my husband at will. It its not from forgetting or lack of heart, but life keeps becoming more difficult, there is less work and everything [the cost of living] goes up.” 31 With the help of veterans’ associations, the families of aliénés worked to ameliorate the plight of their loved ones while also improving their own financial situations. Advocates for wives, children, and “ascendants” (that is, parents) took aim at article 55 of the 1919 pension law, which set forth how a mentally alienated soldier’s pension should be distributed. As it was originally written, article 55 specified that the pension given to a veteran in a mental institution would first be used to pay for his institutionalization fees. The state supplemented the institutional fees if necessary, but only up to the “ordinary” (lowest) level available. If the veteran had a wife or children, the appointed administrator of his estate would deduct money from the pension for the family. Wives received the equivalent of a widow’s pension of “reversion”—a small pension given to widows whose husbands were pensioned but whose deaths were unrelated to military service. If, after these deductions, there was something left of the pension, the surplus would be used to pay for a higher quality of care for the veteran while institutionalized. In the event the patient was released, he could keep the remainder.32 Some found the equation of an aliéné’s wife with a widow revolting, but others acknowledged the unfortunate similarities. Like true widows, many wives of aliénés had effectively lost their husbands for good. These men were

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no longer functioning as working, thinking, feeling members of society or of their families. Often miles away from home, interned husbands saw their wives infrequently, and their relationships deteriorated. Moreover, aliénés no longer provided financially for their families. Thus they were “lost” several times over. Unlike true widows, however, who could reconstitute their homes by remarrying, the wives of aliénés were forced to suffer alone, without the hope of improving their situation. The pension that wives of aliénés received was far too little to help them manage household expenses. In 1923, the pension of reversion was a mere five hundred francs a year, or less than one and a half francs per day. For many women, this sum was insufficient even to allow them to visit their interned husbands with any regularity. Perhaps, suggested one advocate of wives’ rights, the wives of aliénés could at least receive free train fare: The situation of the widow is perhaps even less precarious [than that of the wife of an interned veteran] since she can still . . . create a new home, whereas her sister of misery, the wife of the mort-vivant, what can she hope for? To her, one refuses not only subsidies, but also the means of going to see her poor husband, too often interned far away from her home. The brain-injured soldier [Le blessé du cerveau] has, however, like his comrades in combat, won a partial ownership of all the railroad companies. Do you think [these companies] would be ruined if they made a gesture of recognition by providing free fare, two times a year, to all the women whose husbands were interned following the war?33 Fortunately, the wives and families of aliénés found advocates among veterans’ groups and other associations that looked out for the downtrodden, lobbying for legislative change on the behalf of families and mounting relentless press campaigns. In the pages of the Journal des mutilés et réformés, René Poudevigne, the general secretary of the Federation of Associations for Aid and Protection, crusaded tirelessly on the behalf of aliénés and their families. In almost monthly articles, Poudevigne argued that article 55 of the law of 1919 should be deleted. Poudevigne contended that article 55 violated the creed that was supposed to serve as the fabric of the military pension law: the right to reparation should apply to all victims of war equally. According to Poudevigne, article 55 was “antidemocratic,” since it was particularly unfair to aliénés and their families.34 He maintained that the injuries of these men were not substantially dif-

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ferent from those of other soldiers.35 Yet article 55 created a special situation for them—a fact that was contrary to both the right to reparation and the most elementary rules of justice.36 Poudevigne was not opposed to the wife of an aliéné receiving a widow’s pension. However, he argued that she should receive the higher “exceptional” rate, instead of the rate of reversion.37 The exceptional rate was given to widows whose husbands died from wounds received as a result of military service.38 Through the work of Poudevigne and others, potential revisions to article 55 were proposed to parliament in the mid-1920s. In late 1925, one such proposal was presented by Jean Goy, a Moderate deputy from the Seine and the president of the Union nationale des combattants, one of the larger veterans’ associations.39 Goy noted that the then-current amount of nine hundred francs per year that the aliéné’s wife received did not “permit her to survive.” He continued, “This sum, which represents hardly more than 2 francs per day, certainly does not cover her transportation fees from her home to the hospital. Moreover, if she wants to improve her husband’s lot [the level of his institutional care], she often must devote herself to hard work, from which the children [consequently] suffer.” 40 Like Poudevigne, Goy supported legally equating the wife of the aliéné with the true war widow: Let us compare these two situations: “war widow” and “wife of interned.” . . . The damage is the same, so it follows that the pension of the wife of the interned should not be less than that of her sister in misery. To reinforce this thesis, we can add that the situation of the interned soldier’s wife is even more precarious, since if the widow is able to, she can, if need be, create a new family, it is impossible for the wife of the interned to envision this eventually. . . . Her situation is even more lamentable . . . since . . . the death cannot be erased. She lives with her mort-vivant. It is the nightmares of her nights, often made sleepless.41 Goy proposed giving wives the widow’s pension at the exceptional rate. Meanwhile, ascendants would receive a sum equal to the allocation of ascendants of deceased soldiers as set forth by the law of 1919. Goy’s proposal, however, left intact the provision that the state (via the pension) would only pay a veteran’s institutional fees sufficient to cover the ordinary regime. Goy’s bill received a favorable response from the parliamentary Commis-

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sion of Civil and Military Pensions, whose reporter noted that the situation for wives of aliénés was so unbearable that some people had proposed amending the divorce laws so that these women could remarry and improve their financial situation.42 The bill’s progress slowed, however, as parliamentary committees and the Department of Finance discussed it and proposed subtle changes to it throughout the spring of 1926.43 The budget for 1927, passed on December 19, 1926, finally altered article 55.44 An amendment gave the wives of aliénés the exceptional pension rate, which represented a significant monetary increase. Wives would henceforth receive 1,440 francs per year—a 60 percent increase from the pension of reversion.45 Despite the improvements effected by the law, however, there were still important changes that needed to be made—changes that would impact the daily lives of aliénés themselves.

The Marriage Penalty Veterans’ advocates found additional inequities in the pension law of 1919 as it related to the care of psychologically troubled former combatants. According to the law, married men had less money to pay for better accommodations than single veterans, who had no dependents. Family men were thus forced to endure worse institutional conditions than single men simply because they had families. According to one advocate for veterans’ rights, an interned veteran in 1922 might have received a pension of 3,400 francs per year.46 With that sum, a single man in the Eure-et-Loir region could buy third-class care in the departmental asylum, which cost 8 francs 6 per day, in addition to a small upkeep fee for laundry or other services. Third-class care included better food than what was provided for the fourth class (called the “common regime”), as well as a room that was separated from many of the institution’s chronic civilian cases. A married man, however, whose wife received 500 francs of his pension (the reversion rate in place at the time), could only afford fourth-class care, which cost 6 francs per day plus the upkeep fee. At the common-regime level, the veteran received no better care than that of indigents. The situation was worse for married aliénés in the Seine, where institutional fees were higher. Whereas aliénés (single or married) sequestered in provincial asylums might still have a small bit of their pensions left over after asylum fees and family allocations were paid, the aliéné of the Seine had noth-

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ing left. As one veterans’ advocate noted, the maximum pension possible in 1925 for former infantrymen was 5,320 francs, or 14 francs 57 per day. Though the daily cost of most departmental asylums was between 6 and 12 francs per day, fees for asylum care in the Seine were higher and could easily exceed a patient’s pension.47 Even if single men stood a chance at receiving a remainder, married men certainly would have had no such luck. Madame J. Ancelet, the vice president of the Union Ardennaise des mutilés et réformés, supported one of the propositions to amend article 55, which placed alienated veterans in a category superior to the ordinary regime, though she believed more could be done: “[The amendment] will permit the married aliéné to enjoy the comfort to which he is entitled without his family having to intervene, since the State will take to its charge the difference . . . between the price of hospitalization and the rate of the pension….That is an amelioration, but we had hoped for better!” 48 She and her fellow advocates had wanted nothing less than the complete suppression of article 55, “which created two categories of aliénés of war: married and single.” 49 Until the suppression of article 55 could be achieved, she insisted, the married aliéné and his family would suffer needlessly. Over the course of the interwar period, legislators did cede to pressure by veterans’ organizations to raise pension rates for physically wounded veterans in order to keep up with the fast-rising cost of living. Legislators were gradually convinced to vote more money for the wives, children, and ascendants of alienated veterans. Politicians did little, however, for the alienated former soldiers themselves. Still sequestered in public asylums, many aliénés still found themselves treated like—and with—those labeled as degenerates.

Hospitals versus Asylums While some veterans’ advocates focused on the inequity between single and married aliénés, others saw the underlying problem as the legal disparities between the mentally ill and the physically ill. Article 64 of the 1919 pension law (which pertained to veterans with physical problems) promised that the state would cover medical fees for wounds or maladies contracted or aggravated through military service. A physically wounded or ill veteran could freely choose his own doctor as well as his own medical facility. If he chose a private institution, his fees would be covered up to the rate of the civil ward in the public hospital closest to that establishment.

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No similar benefit was available to veterans interned in mental asylums. Their institutional fees were deducted from their pensions. The symbolic significance of this inequity was not lost on veterans’ advocates. Men who had succumbed to psychological disorders as a result of the war and who required institutional care were viewed as a breed apart. Just as it had been during the actual conflict, patients suffering from psychological wounds of war were not considered the equals of those who suffered from physical wounds. No matter how hard veterans’ advocates tried to suggest similarities between the psychologically wounded and other mutilés, the pension law imposed a sharp dividing line between the two groups. The result was a huge discrepancy in the amount of pension that they received and in the quality of health care available to them. This inequity underscored the importance of medical diagnostics in the lives of veterans. While it was easy to distinguish a mentally retarded soldier from one with gangrene, the difference between a mentally alienated soldier and one suffering from an organic neurological condition was often more slight. The medical decision to place a soldier in one category or another had enormous monetary, medical, and social repercussions for that soldier and his family. A soldier with a neurological condition could receive free medical care in a dignified medical hospital and still garner a military pension. A mentally alienated soldier might be sequestered among indigents in a public asylum where asylum fees would be deducted from his pension. He and his family would be left with little money for daily expenses and also with the stigma of institutionalization. René Poudevigne and other veterans’ advocates protested noisily in the press about the inequities that unjustly penalized mentally alienated veterans. According to Poudevigne, leaving aliénés responsible for the costs of their own care went against the first principle of the pension legislation of 1919, namely, that all veterans were guaranteed the right to equal treatment before the law. He asked, rhetorically, “Is it not an embarrassment for a country like France to have so little for citizens who have left their mental faculties to the service of a collectivity?” 50 Evidently, he added bitterly, these men had no political utility for the next election. The legal divide between physical illness and mental illness caused additional financial inequities that disadvantaged mentally ill veterans. While many psychologically troubled former combatants required internment in asylums, a far greater number were released to their families. These men were either cared for at home or, in rare cases, were sent to private clinics. Both options were costly. When family members assumed caretaking responsibilities,

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they were often forced to relinquish opportunities for regular, paid employment. To make matters worse, mentally ill veterans were denied the special allotments that were available to physically ill or wounded soldiers who were cared for outside of hospitals.51 Article 10 of the military pension law stipulated that mutilés who were incapable of being cared for in institutions and who required specialized home care could receive a special allocation to pay home healthcare providers or to compensate family members who assumed caretaking roles. That allotment was not available to mentally ill veterans living outside of asylums.52 Legislators and administrators justified their refusal to give allocations to mental patients by arguing that families would abuse the system, exploiting the plight of the mentally ill for monetary gain.53 Without those allocations, however, the financial situation of most psychologically troubled veterans outside of asylums was precarious. Denied full pensions, refused allocations to pay for outpatient care, and often unable to work, they were at a severe financial disadvantage compared with their physically disabled compatriots. Adopting one of the common critiques that psychiatrists leveled against the pension law, Laûx suggested that those injustices revealed a misunderstanding about the nature of mental illness on the part of legislators. Legislators incorrectly assumed that all mental patients were dangerous or incurable and therefore required institutionalization.54 They failed to realize that there was a considerable number of veterans with milder ailments who could be cared for at home or in more dignified institutions. “These patients have not lost all reason,” wrote Laûx. “These are the melancholics, the manics, the neuropaths, etc. Many of these patients, thanks to article 10, could receive the care that they require at home.” 55 Sending these patients to asylums, he contended, could make their conditions worse. Repeating a maxim coined by Roger Mignot, the former director of Charenton–Saint-Maurice, Laûx asked, “Where does insanity begin? For many, at the door of the asylum. . . . Removing our comrades from the milieu to which they are accustomed . . . aggravates their state. That is a fact.” 56

Legislative Efforts Persistent pressure on parliament by vocal supporters of alienated veterans did succeed in correcting some of the inequalities in the pension law during the interwar period. After securing the “exceptional” widow’s pension rate for the wives of aliénés, René Poudevigne and others made additional demands on leg-

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islators on their behalf.57 Poudevigne called for the same right to employment that veterans enjoyed for the wives of aliénés, the allowance of at least two free trips per year to visit interned husbands, and, in the event of the husband’s death, the free transfer of the body from the asylum to the home.58 Meanwhile, veterans’ advocates, including Poudevigne, continued to campaign for changes that would improve the quality of life for interned aliénés themselves. Given the slow pace of legislative change, not to mention the low electoral value and lack of public interest in issues pertaining to aliénés, those campaigns were forced to stretch over two decades. Although Poudevigne could write in 1929 that the country no longer ignored the existence of mentally alienated veterans, he admitted that the continuing goal of advocates like himself was to remind the public of these men “as often as possible.” 59 The first legislative success in ameliorating the plight of interned veterans came ten and a half years after the war’s end. The law of finances (that is, the budget) passed on April 16, 1930, finally specified that married aliénés should not suffer from inferior care simply because of their marital status.60 Reinforcing that position, the phrase that had obliged the state to cover fees only up to the common regime of care was removed entirely from the law. But veterans’ advocates were not content to stop there. Psychologically troubled veterans were still required to pay for their own institutional care, and they were still denied special allotments for home care. In short, they were still legally distinguished from their physically ill or injured brothers in arms. Moreover, argued Antoine Sapin, another supporter of mentally alienated veterans, revisions such as the one made in 1930 changed little in practice.61 As long as asylum fees were deducted from veterans’ pensions, interned veterans—whether married or single—would be hard-pressed to afford decent care within the asylum. The minister of pensions had issued a circular on May 20, 1930, reminding departmental prefects that directors of asylums were to place mentally alienated veterans in the “highest class that would be susceptible of being paid by the pension,” regardless of the patient’s family situation.62 But as Sapin noted, in most asylums there was only a single class of care: “In asylums of the Seine and Rhône, the shocking inequalities existing between married and single aliénés of war will remain since there is a uniform daily price for the day whatever the situation of patients.” 63 Even in institutions with several classes, the daily cost of the ordinary regime was still more than a veteran’s pension. In the public asylum of Châlons-sur-Marne, Sapin reported, the daily cost for indigents (that is, the common regime) was 13 francs, or 4,745 francs a

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year. The class above it cost 20 francs per day, or 7,300 francs a year. The annual pension of an alienated veteran was 7,160—too little to allow the former soldier to rise above the common regime. Sapin’s protest was heard loud and clear in the Chamber of Deputies, where, in January 1931, deputies quoted his article verbatim as part of their proposition for a new law.64 Those deputies strove to guarantee the same rights for married aliénés as for single ones, to wipe away treatment inequalities between different asylums, and to enable veterans to receive better care than the common regime. Their proposition had two essential components, both of which had been included in Sapin’s article. First, the full (100 percent) pension given to the interned veteran should be used only to pay for hospital fees and to ameliorate his situation within the institution. Second, the allocation given to the wife of an aliéné should be equal to that of a war widow and should come from a fund distinct from the husband’s pension. The Commission of Pensions, which reviewed the proposition, wholeheartedly supported it. The reporter, François Peissel, wrote: Of all the victims of war, the most pitiable are unquestionably the aliénés. The pity that is aroused by their mental state, their internment, the nightmare in which they do not cease to live and that perpetuates, for them, the horrors of war, should also be extended to their family and in particular to their wives, their children, and their parents.65 He stipulated clearly that spouses and ascendants of aliénés should receive pensions independent of veterans’ pensions so that veterans could apply their money toward the amelioration of their own situation. Yet despite this strong support voiced by the Commission of Pensions, the lethargy of the Third Republic legislature and the low political value of supporting the mentally ill delayed action. It was not until the end of 1937, six years later and nineteen years after the end of the war, that another legislative change was made to the pension law. In the end, parliament did not consent to the promulgation of a new law, as deputies had requested in 1931. Instead, it chose to make yet another small change to article 55 of the original military pension law. The budget passed on December 31, 1937, added the following, still vague, clause to article 55: “In all cases, interned aliénés must benefit from a minimum special regime, comfortable and constant.” 66 The specifics were to be set forth by ministerial decree, though even that final administrative act

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was delayed by governmental torpor. A year later, in December 1938, deputy Paul Boulet reported that the government had yet to take action.67

The Value of the Struggle The long, difficult struggle that mentally disturbed veterans, their families, and their advocates undertook to exact greater pension allowances is entirely understandable, given the huge impact that those monetary increases would have had on their lives. In 1925, when the wife of an aliéné received a mere 500 francs per year as a pension, bread in Paris was 1 franc 63 per kilo. One dozen eggs was 8 francs; one kilo of steak was 19 francs 50.68 To receive an increase to 1,440 francs per year, as wives of aliénés did in late 1926, was significant indeed. Still, the pensions given to the wives of aliénés would never have equaled the wages of their husbands had those men been able to return to their prewar jobs. In 1925, a wood lathe operator in Paris earned 4 francs per hour; a tailor earned 4 francs 50 per hour. Unskilled laborers, such as mine workers, earned on average 23 francs 72 per day.69 Even those working-class men could have earned more by far than what was given to their wives as a pension. As veterans’ advocates lobbied for national legislative changes that would raise pensions for all former combatants, many veterans—such as the shoemaker profiled in the last chapter—began individual struggles to collect every franc they could. In many cases, those struggles continued for years. Veterans submitted claims and appealed pension decisions with the hope of maximizing their allowances. Unfortunately, they met stern resistance from departmental administrators and politicians who sought to prevent swindles and to exercise tight control over the staggering costs of pensions. Though the law of 1919 purported to inaugurate a new era in military pensions, veterans often found that they still had to fight for what was due to them.

Forgetting and the Forgotten Administrative transfers and economic troubles kept many families physically separated from their mentally disturbed husbands, brothers, and sons. Other mentally alienated men were distanced from their families for an even more pitiable reason: they could not provide their own identity. Either psychologically traumatized or physically wounded, some soldiers, even years after the

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armistice, could not tell doctors who they were or how to contact their families. After numerous transfers through the multi-tiered hospital system, many of these living unknown soldiers were planted in insane asylums for lack of a better place. Families of missing soldiers, clinging to the hope that their loved ones were still alive, tried to find those lost men in hospitals and asylums, where soldiers with head injuries or memory disturbances were placed. But searching for a familiar face (which they might not have seen in years) among a legion of dirty, malnourished internees with the sunken eyes of aliénés was destined to end in disappointment for many of those hopeful families. The press attempted to facilitate reunions of families with lost soldiers. In 1922, the photos of several amnesiacs were published in the Journal des mutilés, as well as a number of other French dailies, with the hope that their families would identify them.70 Like other interned veterans, they too were called “les morts vivants.” Photos of one amnesiac veteran elicited multiple responses. Anthelme Mangin, as he was named by doctors, was recognized by fifteen families. In the years that followed, and as stories about Anthelme multiplied in the press, hundreds of families claimed that he was their lost son, brother, or husband.71 The number of responses should not have been surprising. Anthelme’s face, which was reproduced in the papers, was “characteristically French,” according to a journalist reporting the story in 1926.72 And in addition to holding out a last hope of recovering a lost loved one, respondents may also have had another reason for claiming Anthelme: the possibility of receiving his pension.73 By 1936, no family had yet been able to successfully claim Anthelme as their own.74 Eighteen years after the war had ended, he remained at an insane asylum in Rodez. Pleas on his behalf in the press, and even a review of the case by the minister of pensions, did little to ameliorate his situation. The best journalists could do, it seemed, was to wish him well: “Let us wish that the interned of Rodez finds his family and reason, since it is truly atrocious, this role of ‘unknown soldier,’ which makes to the Other [unknown soldier], the one of the Arc de Triomphe, such a painful counterpart.” 75 Grieving families, however, refused to give up hope. Several families, in fact, brought the matter before the courts in an effort to have Anthelme officially identified. One family succeeded in claiming Anthelme in 1937, but legal appeals, and the commencement of the Second World War, prevented him from ever escaping psychiatric care. After having been transferred to a Seine asylum before the end of the 1930s, he ultimately died in 1942 at the Sainte-

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Anne asylum in Paris, possibly due to malnutrition that resulted from food rationing imposed on French psychiatric patients during the occupation.76

Conclusion When Paul Cassel, the secretary general of the departmental committee for mutilés and discharged soldiers of the Nord department, assessed the situation of mentally alienated veterans in 1922, he called for a broad program of assistance for these silently suffering men.77 According to Cassel, the pension law of 1919 and its accompanying disability table were difficult to apply to them. Yet Cassel did not advocate a complete revision of the law. A bigger pension was not the answer. Instead, mentally alienated veterans needed better assistance, including better hospitalization and improved reeducation programs. Cassel also advised against focusing reform efforts exclusively on chronic, dangerous patients. According to Cassel, the war’s impact on most veterans was depression, not the chronic illnesses that plagued many men interned in asylums. Consequently, reformers should look beyond the asylum when contemplating programs to assist these men. As Cassel wrote, “The effects of this terrible period of five years of war is not manifested in the bosom of asylums. It is more in the street.” 78 Veterans’ organizations could help men whose mental state allowed them to be free of institutional care to find simple jobs that did not require great physical effort. Veterans’ advocates could help assure other men a means of complete rest and isolation. Cassel proposed the creation of “houses of retirement and internment,” where pensioners could be productive with small jobs or simply be allowed a long rest from the stresses and strains of war.79 He believed that such institutions could ultimately help cure mentally ill veterans of their troubles. By the end of the interwar period, however, Cassel’s suggestions, and those of other vocal veterans’ advocates, remained largely unrealized. No new rest homes were created; the pensions given to psychologically wounded men who did not require internment were insufficient to allow them to pay for private care; article 55 of the pension law, which distinguished the mentally ill from the physically ill, and the married from the single, was not completely suppressed; families still remained separated from their interned loved ones; and the pension allocations for aliénés and their families were still too meager to improve veterans’ institutional treatment or their families’ ability to subsist. Although the efforts of veterans’ advocates resulted in some legislative

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changes, parliament repeatedly demonstrated that mentally alienated individuals—even those who had served their country during war—were low on their list of priorities. The Charenton–Saint-Maurice story has an equivocal ending. Pinard did not succeed in reclaiming the entire hospital for expectant and nursing mothers. Though many mentally ill patients were transferred to the provinces and the budget for treating mental patients was greatly reduced, several hundred mentally ill patients continued to inhabit the institution throughout the interwar period. In 1931, Henri Baruk began a renovation of the psychiatric wards of the historic institution.80 In addition to reforming the closed asylum, he introduced outpatient services, built a laboratory of experimental psychiatry (where he used animals as subjects), and created a small open psychiatric service, attempting to keep the institution at the vanguard of psychiatric care. Today, the facility—renamed Hospital Esquirol after the famous alienist—­ continues to cater to mental patients. Charenton–Saint-Maurice’s lasting psychiatric focus indicates a surprising victory for the alienists who tenaciously defended their turf. The majority of patients housed within that institution, however, did not enjoy the benefits of psychiatric care past the 1930s. During World War II, the maternity section was evacuated and the aliénés were neglected. As the hospital’s web site admits, a large number of those patients were left to die of malnutrition during the German occupation.81

Chapter 5 Opening Doors for a Traumatized Nation

Madame P., a war widow and mother of an adult child, was not a good candidate for long-term commitment in a public asylum.1 She did not suffer from deliria, hallucinations, or any other symptoms that might have indicated a severe break from reality. She was not an alcoholic or addict of any sort. She was also not a potential threat to others, nor did she disturb the peace. Nevertheless, Madame P. needed help. She suffered primarily from obsessions and phobias, and at some point she also contemplated suicide. Economic anxiety seemed to be at the heart of her troubles. She was quickly burning through her savings by living in a Paris hotel, and she was unable to conquer the mental disorganization that prevented her from finding a steady job. Madame P. might have had a middle- or even upper-class background, but her depressed economic circumstances would have made it impossible for her to check herself into a private clinic or to pay for private medical consultations. And without the financial support of family, she would not have been able to endure her economic and emotional states at home. Fortunately, by the mid1920s, when Madame P.’s difficulties reached an apex, a new type of public psychiatric service had opened its doors in Paris. This “open” psychiatric service was created expressly for individuals such as Madame P.—mildly troubled people who neither could afford private care nor warranted legal commitment. The creation of open services in Paris represents one of the few success stories for psychiatrists in wartime and interwar France. For decades before the war, psychiatric reformers had tried—and failed—to effect changes in psychi-

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atric practice that might benefit troubled individual patients, a traumatized nation, and their own imperiled medical specialty. But the war provided new opportunities for change. It engendered administrative, economic, and demographic challenges that forced administrators and politicians to consider a variety of new healthcare proposals. Psychiatric reformers capitalized on postwar conditions, producing finely tuned propaganda that underscored the psychological effects of the war and the desperate need for psychic fortification and rejuvenation. According to these reformers, the war had left in its wake a pool of depressed and anxious citizens who desperately required psychiatric care.

The Birth of an Idea When Dr. Édouard Toulouse surveyed French asylums in 1896, he concluded that little had changed over the last century: With their high walls, naked and gray, their buildings . . . extending from the central pavilion in a severe alignment, and their heavy entrance gates, our asylums resemble prisons. . . . Inside, the close surveillance of the personnel, the number of doors, which are never more than ajar, the incessant noise of keys carried in the corridors, the quarters for agitated patients, divided into small and obscure cells, . . . the straitjackets, . . . the belts and padlocks still too widespread, all manifest the constant fear of an escape and the habit of a general discipline applied without discernment.2 Despite the optimism of early nineteenth-century alienists and the institutional reforms that psychiatrists had sought to achieve, asylums remained overcrowded and dirty. They continued to cater to poor men and women, many of whom were deemed chronic and incurable. Early in his career, Toulouse began a quest to improve institutional conditions and to offer therapeutic alternatives to the largely custodial asylum. That quest blossomed into the mental hygiene movement. Mental hygienists—who included doctors, politicians, and civil administrators—endeavored to stem the rising tide of mental illness in France while also helping individuals escape the emotional, social, and legal scars of internment in public asylums. The mental hygiene movement folded into the broader, ongoing efforts of public health reformers and social hygienists in France’s Third Republic, who strove to reverse declining natality and to bolster the physical, material, and moral

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health of their nation’s faltering population.3 Mental hygienists contended that mental illness was a blight on par with tuberculosis, alcoholism, and syphilis. Like those social scourges, mental illness not only affected individuals, it also threatened the nation’s collective vitality. Mental hygienists argued that promoting mental health and curing mental illness were indispensable in strengthening France. Following models for preventive care and early, active treatment established by public health reformers, French mental hygienists planned to launch social outreach programs to identify, track, and treat predisposed individuals and those with acute maladies before their conditions deteriorated and necessitated institutional commitment.4 Toulouse and his colleagues were inspired by the work of twentieth-century American mental hygienists, such as Clifford Beers, Thomas Salmon, and the Swiss-American Adolphe Meyer.5 Like those men, French mental hygienists believed that fostering better mental health demanded the creation of a new kind of facility. The psychiatric hospital, rather than the asylum, was to be the new locus for psychiatric treatment. More than just giving old buildings new titles, French mental hygienists wanted to re-found psychiatry on a medical model. Like the early nineteenthcentury forefathers of French psychiatry, Toulouse insisted that mental illness should be actively treated by medical doctors. But while the founders of psychiatry had failed to cure their troubled patients, Toulouse believed that his specialty was now better prepared to do so, rearmed as it was with the latest advances in science and medicine. Mental hygienists—many of whom were alienists—also realized there were important professional advantages to reaffirming the ties between psychiatry, science, and medicine. They believed that the psychiatric hospital might help to raise their medical specialty out of its miserable state. Toulouse first discovered a model for open psychiatric assistance during a trip to Scotland in 1897. The open-door system used in Scottish asylums divided the institution into a hospital (for observation and treatment of acute cases), a “chronic-block” (for severely troubled patients), and an area where certain patients could work in exchange for cigarettes or similar rewards, but not money.6 The facility was open in that select patients were allowed to circulate freely inside and outside of the asylum. In 1899, Toulouse proposed to administrators a wide range of institutional changes in the department of the Seine.7 He recommended transforming at least part of closed asylums into treatment and observation centers so that

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doctors could cure patients whose troubles had yet to evolve. The creation of open pavilions, meanwhile, would allow patients to work rather than forcing them to remain idle in chronic wards. Administrators did not open their asylum doors in 1899, but that temporary setback did not diminish Toulouse’s commitment to reform. He continued to recommend improvements to psychiatric care and to found organizations that would encourage active treatment of curable patients. Lobbying for legislative change became another key component of Toulouse’s efforts. He and his colleagues supported parliamentary initiatives to revise the asylum law of 1838, which had established the national system of asylums and had defined the modes of asylum admissions.8 Toulouse hoped to add provisions for open services, which would enable patients to receive treatment without being subjected to the stigmatizing legal process of asylum commitment.

The Postwar Environment By 1920, Toulouse had been working toward those goals for more than twenty years.9 He had served as medical director for a women’s service at Villejuif asylum, created a laboratory of experimental psychology, established and edited several medical journals, and participated in professional societies. He also had published frequently, writing books and articles for medical journals and daily newspapers that covered a range of topics, from sexology to studies of the intellectual superiority of celebrities such as Émile Zola and Henri Poincaré. Most of his writing, however, was propaganda for the hygienic cause. As his career progressed, Toulouse increasingly gave up the day-to-day practice of psychiatry to devote more of his energy to advancing hygienic initiatives. According to Paul Sivadon, one of his students, “Édouard Toulouse was phobic: One hardly saw him in the [psychiatric] services. But he was a marvelous organizer, and he was known to surround himself with valuable collaborators.” 10 Moreover, Toulouse was an unyielding leader whose dictatorial directives moved his peers to nickname him “tyrant” and “the emperor.” Those qualities inspired loyalty among some and strong resentment among others. As Sivadon reflected, “[The psychiatrists] Bonnet, Demay, de Clérambault advised me strongly against wasting my time with this ‘dishonest man.’ I hastened to disobey them.” 11 Despite a widespread distaste for Toulouse’s managerial style, his goal of creating an open psychiatric service garnered increasing support among doc-

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tors, departmental administrators, and members of the French parliament following the war. That support was due in part to the emergence of several practical challenges that faced healthcare facilities in the war’s aftermath. The war left medical hospitals and mental asylums in a terrible state of disrepair. Institutions were severely disrupted when the military requisitioned them to care for soldiers. Some buildings sustained physical damage during the conflict; most facilities suffered staff shortages as men went off to war and others fled cities for the safety of the countryside.12 The war’s end brought little relief. Hospitals and asylums continued to care for injured soldiers years after the armistice.13 Influenza and encephalitis epidemics put additional strains on the healthcare system. Postwar demographic changes exacerbated the challenges facing French healthcare institutions. Soon after the armistice, civilians who had been dislocated by the war came streaming back to their cities, towns, and villages. Civilians who had been caught behind enemy lines and those who had left their homes voluntarily to escape bombs and artillery shells returned. Demobilized soldiers came home as well. From the armistice through October 1919, 4.5 million men were released from service.14 At the same time, Germany released more than half a million French prisoners of war.15 Though the percentage of individuals requiring medical assistance was not unusually excessive, the appearance of any additional sick people on the doorsteps of hospitals and doctors’ offices burdened an already beleaguered healthcare system. France also began to experience a massive wave of immigration.16 More than 2 million immigrants came to France in the 1920s in search of work.17 To immigrants, France appeared to prosper during that first postwar decade. Although the fluctuating value of the franc caused French politicians great concern, France’s economic situation still appeared much less precarious than that of some of its European neighbors. Beyond its economic promise, France also drew immigrants for its relative political stability, freedom, climate, culture, and physical beauty. France stood to benefit from immigration: among other things, immigrants helped to repopulate factories. Nevertheless, many politicians, administrators, and doctors believed that immigration placed an additional strain on the nations’ healthcare system. By 1925, 14 percent of all those hospitalized in Paris were foreigners.18 In 1933, just over 11 percent of men and nearly 8 percent of women in Seine mental asylums were immigrants.19 Although these percentages were only slightly higher than in prewar years, doctors and administrators nonetheless saw cause for concern.20

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In light of these many practical challenges, administrators began to reorganize healthcare institutions; and, as they did so, they reduced the number of beds for aliénés. Asylum populations had diminished during the war, and administrators wrongly assumed that the trough would last. Moreover, they believed that the protection of expectant and nursing mothers and the isolation of tuberculosis cases were more crucial to rebuilding the nation than the care of lunatics. As mentioned in the previous chapter, the French government attempted to convert the national asylum of Saint-Maurice into a maternity home in 1920. In 1921, the Seine’s General Council decided to suppress 1,500 additional beds previously allotted to aliénés in departmental institutions.21 While administrators did not expect the population of mentally ill people to rise again, they did realize that they might need to compensate somehow for the loss of spaces previously allotted to aliénés. Consequently, they were receptive to entertaining proposals for new modes of treatment. All of these factors—the disorganized and battered state of healthcare facilities, the demographic changes that contributed to institutional overcrowding, and the decision to prioritize other maladies over mental illness—helped to create a climate favorable to the approval of open services. But it was the relentless, skillfully crafted propaganda of Toulouse and his colleagues that ultimately brought about success. In campaigning for the open service in Paris and the subsequent multiplication of open services throughout France, those reformers crafted a message that focused on the war’s effects on the French nation. Toulouse and his colleagues framed their argument in terms of national challenges. The problem of the falling birth rate and the perception of a degenerating nation had troubled France for decades. But the loss of a generation of able-bodied men during the war had increased the urgency of these crises. Regeneration was a matter of national survival. Reformers argued that the tremendous loss of life in the war highlighted the need for programs to strengthen the physical and mental health of the surviving population. They insisted that improving individual health could enhance the military strength and material well-being of the nation overall. France, said Toulouse, needed to fortify its “human capital.” According to Toulouse, “The war . . . destroyed or put out of the state of work the youngest, most vigorous men. . . . This human capital has been reduced further by the diminution of births and finally by the lower quality of offspring conceived [le peu de valeur des produits conçus] in a period of deprivation and of physical and emotional misery. The great national

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challenge therefore will be the restoration of this capital.” 22 Reestablishing human capital meant not only preserving or enhancing the vigor of relatively healthy individuals, but also reintegrating individuals whose health had been compromised. Toulouse argued that disabled veterans, individuals with tuberculosis and syphilis, and nervous and mentally alienated individuals should all be put back to use by their battered nation. Open-service advocates also insisted that there was a growing postwar population of citizens whose resistance to mental illness needed strengthening. In proposals for open services throughout the interwar period, doctors and healthcare administrators argued that the psychological effects of war and the ensuing economic hardships had created a group of potential patients, both veterans and civilians, whose conditions warranted psychiatric care but not internment. Mainly suffering from depression, anxiety, or other neuroses, this group, said open-service advocates, deserved active psychiatric treatment in a respectable setting. In 1920, the French premier was sufficiently convinced by the arguments for hygienic initiatives that he created a Ministry of Hygiene, Assistance, and Social Planning to oversee these projects on a national scale. The first minister, Jules-Louis Breton, established several committees to coordinate hygienic work, including a Committee for Mental Hygiene.23 From that Committee, which included the leading hygienists Toulouse and Georges Genil-Perrin, the League of Mental Hygiene (Ligue d’hygiène mentale) was born less than a year later. The League’s primary objectives were to study and implement the proper measures to prevent mental troubles, to ameliorate treatment conditions for the mentally ill, and to extend mental hygiene to the domains of individual, scholarly, professional, and social action.24 The League established programs to prevent crime, reduce delinquency, and protect the health of mothers and children. It aimed to strengthen the “race” by promoting eugenic measures, such as the restriction of marriage of and reproduction by syphilitics as well as the sterilization of dangerous and diseased individuals.25 Toulouse hoped that the creation of the Committee for Mental Hygiene and the League would be important steps toward building a new type of society—a “biocractic” state, in which the actions of government would be driven by the rational functioning of society, as determined by scientists like himself in small, soviet-like committees.26 Toulouse’s biocracy was never realized,27 but with the League’s assistance,

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Toulouse did achieve his longstanding goal of creating an open psychiatric service in Paris. In December 1920, Frédéric Brunet, honorary president of the League and member of the Seine department’s General Council, asked the Council to implement open services within Seine asylums.28 In his proposal, Brunet highlighted the war’s role in creating a population of citizens who required this particular type of assistance. Some potential patients were veterans who had been struck with mild neuropsychiatric disturbances during the war, often following “commotions.” These “petits mentaux,” as they were often called, were treated in specially designed open services at Maison-Blanche and Ville-Évrard during the war. But after the armistice, they had nowhere to turn to. Hospitals often did not take them, since their conditions did not require urgent treatment, and asylums were inappropriate for them, since those men did not require formal asylum commitment. Brunet argued that assisting these individuals was not only possible, it was also essential for rebuilding the nation: “These psychopaths, left without direction, are very often incapable of readapting to social life. They exert an unfavorable influence on their entourage, remain all more or less diminished in their productivity and can even be pushed to antisocial reactions, even though many of them could be rehabilitated and recuperated by suitable care and supervision; and that is a loss for the French collectivity, already so deprived of workers by the war and depopulation.” 29 On the advice of Henri Rousselle, president of the Council’s Commission of Assistance, the General Council agreed in July 1921 to create a single institution in Paris for the treatment of lucid, non-dangerous patients whose psychological states did not necessitate internment according to the asylum law of 1838.30 Toulouse’s service opened just under a year later.

Opening Doors On June 16, 1922, Paris’s first public open psychiatric service, located on the grounds of the Sainte-Anne asylum, began accepting patients.31 Initially called the Service libre de prophylaxie mentale (the Free Service of Mental Prophylaxis), the facility was open in that there were no legal formalities to regulate patients’ entries or departures. Unlike in asylums, where both voluntary and involuntary admissions were formal legal processes that required a medical certificate, admissions to the open service were watched no more closely than admissions to medical hospitals. The service was placed on the grounds of

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an asylum to demonstrate symbolically its close relationship with psychiatry. Still, it was administratively separate from Sainte-Anne,32 its wards were discrete from the asylum’s locked wards, and its entrance was distinct from that of the asylum so that patients could avoid embarrassment when coming for treatment. In organizing this open service, Toulouse found inspiration in nineteenthcentury Scottish asylums and the new American “psychopathic” hospitals. But he also drew on models for care that had emerged during the war.33 For example, wartime doctors demonstrated the efficacy of frontline neuropsychiatric centers that focused on active and early treatment of disorders. The success of open neuropsychiatric services for patients with head traumas, such as those implemented in Maison-Blanche and Ville-Évrard during the war, reinforced the advantages of segregating patient populations according to their disorders and providing specialized treatment for patients with mild neuropsychiatric disturbances. Finally, the wartime organization of tuberculosis services proved the utility of centralized, rationalized approaches to socio-medical concerns. Toulouse combined all of these influences, designing a center that he believed would provide effective treatment, address the practical challenges of postwar health care, support hygienic philosophy, and help improve the status of the psychiatric profession. There were three main components to Toulouse’s open service: a dispensary, a psychiatric hospital, and a cluster of laboratories.34 The dispensary provided psychiatric consultations, treatment, and referrals to other medical specialists, all on an outpatient basis. Each patient first underwent a general psychiatric evaluation. If the case called for it, blood, urine, or spinal fluid was collected and sent to a laboratory. A patient might then be referred to a psychiatric specialist or a specialist in another field for consultation. Anxious and suicidal patients, for example, were sent to Suzanne Serin, a young mental hygienist and student of Toulouse who would later use research conducted through the open service in an influential study on the causes of suicide.35 Patients requiring psychotherapy were sent to Eugène Minkowski, a Russian émigré who would become a leading figure in French psychiatry following World War II. Non-psychiatric specialists to whom patients could be referred ranged from neurologists to stomatologists.36 Toulouse’s inclusion of specialists from other fields underscored his commitment to collaboration between psychiatry and medicine proper.

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A variety of treatments were employed at the dispensary and at the psychiatric hospital, including therapeutic injections, electrotherapy, ultraviolet rays, and the old asylum standby, baths.37 The type of psychotherapy offered depended on the therapist. Advocates of psychoanalysis (still a small sect in interwar France) probably employed only abbreviated versions of the Freudian method. It is unlikely that analysts were able to see patients as consistently as strict Freudians would have recommended. After the initial exam and any provision of treatment at the dispensary, some patients were ultimately encouraged to accept voluntary or involuntary internment in an asylum. Although Toulouse wanted to encourage patients to seek psychiatric care without the threat of institutionalization, he did not want his open service to become a refuge for dangerous individuals attempting to avoid involuntary commitment.38 As an adjunct to the dispensary, Toulouse created a social service. Based on the American model for tuberculosis services, the social service was meant to sponsor scientific research on the environmental factors that influenced the development of mental illness and to extend the reach of mental prophylaxis and surveillance.39 Social-service assistants questioned patients and their families about their social situation, compiling statistical information to target future outreach programs. Because some patients came by themselves or were unable (or unwilling) to provide the necessary information, assistants occasionally mounted inquiries into patients’ backgrounds. The social service also tracked patients leaving the dispensary who, in their view, might be susceptible to exhibiting “antisocial” reactions, such as aggressive acts or attempts at suicide.40 As another adjunct to the dispensary, Toulouse created a “home service” to treat—or intern—patients who refused to come to the dispensary for consultation. He noted that family doctors generally were reluctant to initiate commitment procedures for their patients. The police, meanwhile, only intervened in cases where individuals disturbed the peace. Toulouse’s staff, however, could visit individuals at home when alerted to trouble by family members. Staff members could deliver a certificate for involuntary internment or commence a voluntary placement. Toulouse also established a patronage committee to help find work for certain patients.41 He firmly believed that many mentally ill individuals could be successfully reintegrated into society. Even chronic patients could find work

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that would allow them to readapt to social life. Work would be good for the patients, good for the community, and good for asylums, which would otherwise remain overcrowded. Patients who required extended observation, repeated treatments, or additional consultations were admitted to the psychiatric hospital. According to its charter, the hospital received patients whose psychopathic state did not require internment, in addition to patients who might later be found to require internment, but who first needed a more comprehensive exam.42 Patients could stay at the hospital for several days, as they might in any ordinary medical hospital. Like the overall organization of the service, the psychiatric hospital was open in that there were no formal laws guiding admission and discharge. Patients could admit themselves voluntarily, without a medical certificate or corroboration from family members. Because the psychiatric hospital was considered to be a hospital like any other, its patients were covered by the law of 1893, which guaranteed the costs of medical assistance for all French citizens.43 Toulouse was adamant about this provision. It was a central tenet of his mental hygiene program that the best psychiatric care should be available to all members of society, not just those who could afford to pay for it. By 1933, the psychiatric hospital at Sainte-Anne had two hundred beds. There were separate dormitories for men and women (divided into rooms with only two beds each), areas for observation and treatment, a dining room, beds for patients recovering from intoxications, a small service for children, and salons in which patients could read, receive visitors, play piano, or listen to phonograph records.44 According to Toulouse, the hospital was well-known and respected in the capital.45 As we will see shortly, however, the hospital, and the open service more generally, did have opponents. The final branch of Toulouse’s service was a collection of laboratories, including labs for biological chemistry, physiology, bacteriology and serology, pathological anatomy, and radiology.46 An additional laboratory for psychology and professional orientation evaluated the scholastic aptitudes of students and the professional aptitudes of workers.47 Toulouse made the laboratories available to the entire Parisian medical community, again seeking to ally psychiatry with general medicine. In addition to the practical advantages that these labs offered for treatment and research, they served an important symbolic purpose: they helped to reinforce the image of the open facility as a place of technology and the active practice of scientific medicine.

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What’s in a Name? Though Toulouse was successful in garnering departmental support for open services, he still needed to sell his particular brand of open service to fellow psychiatrists. His colleagues generally endorsed the concept of open services, but several posed important questions about how those services should function in practice. What should open services be called? What types of patients were best served by them? What were the professional ramifications for such services? Toulouse hoped to establish a precedent by using the term “psychiatric hospital” for the extended-treatment facility in his open service. He and his colleagues believed that using the term “hospital”—like the American “psychopathic hospital”—would help the institution exude an aura of active treatment and reduce the social stigma of seeking psychiatric help. By contrast, the term “asylum” still conjured images of gigantic, dirty buildings where the chronically insane wasted away their lives. But Toulouse could not convince all of his peers. René Charpentier, a doctor who would later become chief editor of the Annales médico-psychologiques, countered that replacing the term “asylum” for “psychiatric institutions” would do little to erase the social stigma attached to psychiatric care.48 He noted that in parts of the country, the word “asylum” did not even need to be spoken to transmit the notion of institutionalization. The mere mention of the town in which a facility was located was enough to reveal a local resident’s fate. Still, Charpentier offered little by way of an alternative. He believed that calling a psychiatric institution a “hospital” was too vague; calling it a “psychiatric hospital” was too specific. Ultimately, he suggested renaming Toulouse’s service Hôpital Magnan, after Valentin Magnan, the former director of admissions at Sainte-Anne.49 Instead, in 1926, three years after Charpentier’s suggestion, the hospital component of the service was named after one of its most ardent supporters in departmental government, Henri Rousselle. By then the Service libre de prophylaxie mentale had been renamed the Centre de prophylaxie mentale de la Seine. But because the hospital was the primary structure in the center, the entire open service was often referred to as “Henri-Rousselle Hospital.” The French minister of health would later settle the issue of nomenclature, officially endorsing the term “psychiatric hospital” in place of “asylum” for all psychiatric institutions.50 In professional practice, however, use of the term “psychiatric hospital” was never guaranteed. Similarly, the term “open ser-

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vice” was not universally supported among psychiatrists. By 1939, a member of the Société médico-psychologique, Georges Daumézon, argued that open services still lacked an adequate name and definition.51 James Rayneau succinctly agreed, saying, “I find the term open service stupid.” 52

Clientele Doctors and administrators had difficulty classifying open services in part because it was unclear what type of patients would be seen there. According to some doctors, the patients best suited for open services were the “petits mentaux.” But what exactly did that term signify? Could it apply to certain diagnostic categories? Or did it refer to a particular—favorable—prognosis? The term “petits mentaux” had first been used during the war to identify minor nervous cases who did not require asylum internment but instead warranted treatment in open neuropsychiatric services. After the war, however, most doctors agreed that the term had lost its meaning. Charpentier, who had a penchant for dramatic utterances, said, “This expression, bad, incorrect, signifies nothing. . . . [It] should not figure into our vocabulary.” 53 René Semelaigne noted that the term was grammatically incorrect, since mental (the root of mentaux) was an adjective, not a noun. Roger Dupouy added that it was impossible to draw up a list of affections that belonged to this category of minor disturbances. After all, a melancholic was sometimes a “petit mental,” with simple depressive, neurasthenic tendencies, but at other times was a “grand aliéné,” with suicidal or even homicidal ideas. François-Léon Arnaud stated that the term was impossible to justify. If it were to be used at all, he suggested, it would replace the term “neurasthenic,” which was often applied haphazardly to melancholics. In the summer of 1922, Paul Strauss, the minister of hygiene, requested a final pronouncement from the Société médico-psychologique about the proper designation of open service patients. After several months of debate, the society recommended against using the term “petits mentaux.” 54 Open services were best suited for patients who did not require internment. The committee chose not to provide a precise list of affections that might qualify patients for these services since diagnostic categories were less important than patients’ reactions to their troubles. The society could, however, exclude patients who required voluntary or involuntary internment due to the “gravity of [their] anti-social reactions.” 55 Chronic or dangerous patients were better treated in

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the closed wards of asylums. Despite this apparent accord among doctors, as late as 1939, psychiatrists were still arguing that the clientele for open services were poorly defined.56 The debate over the designation of the correct clientele for open services was not merely a semantic exercise. In the first place, it had implications for legislative projects. Strauss posed the question as part of his ongoing efforts to revise the asylum law of 1838. Defining the proper clientele for open services was essential in distinguishing open-service patients from patients who required legal commitment. The debate over open services’ clientele also hinted at the deeper issue of the future direction of psychiatry. Toulouse saw psychiatry as a specialty that could and should extend its reach beyond the treatment of severely afflicted patients who were interned in asylums. He believed that psychiatry should reach seemingly normal individuals and individuals with milder ailments to prevent the development of serious conditions. The concept of prophylactic psychiatry was a radical departure for French psychiatric practice. French psychiatrists had long been keepers of the severely disturbed. And while in other countries Freud’s psychology of everyday life had begun to break down barriers between the normal and the pathological, Freud’s influence on French psychiatry at the time was still minimal.57 Still, many French psychiatrists were eager for change. They wanted to demolish the long-held truth that psychiatric treatment was for patients with severe, chronic disorders. Toulouse’s vision helped introduce a fluidity between the normal and the pathological. He asked his colleagues to consider the notion that individuals seen in open services might not fit easily into a clear category because they might not yet be seriously ill. They could and should continue to function in society while receiving treatment. The move toward treating normal and near-normal individuals did not signal the end of hereditary thinking. While psychoanalysts came to believe that anyone could become mentally ill, Toulouse and other French doctors did not agree with that conclusion. As the historian Michel Huteau has argued, Toulouse placed equal value in the ideas of direct, environmental causes and predisposing traits.58 Toulouse’s endorsement of the control of procreation, for example, clearly demonstrates his belief that hereditary factors could contribute to the development of mental problems. Still, Toulouse argued that by taking an active, prophylactic approach to illness, mental hygiene initiatives could help reduce the incidence of inherited defects in society, eliminate the

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environmental factors that might cause mental illness in healthy individuals, and thwart the development of disturbances in all individuals. Toulouse’s service ultimately succeeded in reaching a normal or near­normal clientele. Not only did it treat individuals who came to the dispensary for consultations, it also reached out to the community, following up with patients while they continued to live relatively normal lives. Moreover, the social-­service branch of his organization initiated extensive efforts to ameliorate those individuals’ social circumstances. Prophylaxis meant taking an integral role in the lives of community members to promote health and to inhibit the development of disease. The extent to which Toulouse’s service was willing to intervene in the lives of community members is illustrated by the case of Madame P., introduced at the beginning of this chapter. Madame P. was admitted to Henri-Rousselle hospital repeatedly for obsessions, phobias, and suicidal ideation.59 Although she was released in an improved condition each time, she continued to have difficulty overcoming her obsessions and finding regular employment. Aware of her ongoing troubles, the social service of Toulouse’s organization assisted Madame P. long after she was discharged from the hospital. In May 1924, Madame P. was in poor physical and mental health. Unemployed and anxious about her economic situation, she wrote to the social service, asking them to visit her. Above all, she needed help organizing her life. Madame P. wanted to stay in Paris, but the social-service assistant who saw her recommended that she live with her mother outside the city. The assistant explained that if she continued living in a Paris hotel, she would exhaust her meager savings in only a few days. Madame P. resisted the suggestion, replying that her mother was infuriated with “her manias” and would not receive her.60 The assistant intervened, writing a letter to Madame P.’s mother with the hope of achieving a rapprochement between the estranged women. In June, Madame P. wrote to the social service again, and an assistant visited her at the hotel just hours after the letter arrived. The assistant was welcomed warmly by Madame P., who reclined on a couch, brushing her hair, with her adult daughter beside her. Madame P. recounted the emotional and financial sufferings that she had endured since leaving the open service. The assistant presented a partial solution: the social service had found a job for her as a salesperson at the nearby Potin grocery store, where her daughter already worked as a cashier. Madame P. did not want to refuse the opportunity, but she feared failing at the job. She explained that she had been very weak since

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last leaving the open service, eating little and rarely going out. Nevertheless, she was out of money, so she reluctantly agreed to try the position. In the meantime, a social-service assistant again wrote to Madame P.’s mother, this time asking for information pertaining to the death of her sonin-law, Madame P.’s husband. The social service hoped to obtain a pension for Madame P., whose spouse had been inducted into the Legion of Honor. When the service received the necessary information, an assistant went to the Potin grocery store to have Madame P. sign a formal request for a widow’s pension. But someone there explained that Madame P. had not been seen in days. The assistant then went to the apartment building where store employees lived, but the concierge reported that Madame P. had left abruptly. The social assistant finally found Madame P. back at Henri-Rousselle. Profoundly depressed and suicidal, she had again come for help. A few days later, the social service received Madame P.’s pension from the Grand Chancellery of the Legion of Honor. An assistant then began to arrange a trip for Madame P. and her daughter to Madame P.’s mother, who had been convinced to receive them. An assistant ordered the train tickets and prepared Madame P. for the trip. Nine months later, in April 1925, Madame P. returned to Paris after a long stay with her mother. She contacted the social service several times for assistance with a new job search, and, with their help, she eventually found a position at a bank. The staff at the social service believed that with a widow’s pension and a new job, Madame P. would have enough money to subsist. But when Madame P. visited the dispensary eight months later, in December 1925, she was still having difficulty earning a living. She insisted that her bank job did not pay her enough. She said, “If I fall ill again, it will not be my fault. I do not have enough to eat.” 61 The social service began to assist her once again, this time trying to find her a job in the provinces that would provide her with a sufficient income to live.

The Multiplication of Services Toulouse’s center was the first comprehensive open psychiatric facility in Paris, but it was not the first institution to provide assistance to mildly troubled individuals outside of asylums. For more than a century, private clinics and sanatoria, such as the one Paul Deschanel stayed in, had catered to bourgeois and upper-class men and women with minor nervous and mental

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disturbances.62 Neurologists and psychiatrists had also long accepted paying patients privately: Charcot, for example, maintained a private clientele outside of the Salpêtrière.63 In the public sphere, several hospitals and asylums had implemented outpatient services during the nineteenth century. Charcot, and his successors, saw patients through an external consultation service at the Salpêtrière;64 Sainte-Anne had provided external consultations for patients with psychiatric disturbances and general medical problems since 1868.65 Elsewhere in the country, several doctors had created open psychiatric services years before Toulouse’s service was created.66 James Rayneau had organized the Psychotherapeutic Establishment of Loiret in Fleury-les-Aubrais in 1909. A doctor named Anglade had created an external consultation service at the asylum in Bordeaux. Georges-Édouard Raviart had directed an open service called Esquermes since 1912. Pierre Kahn, too, had directed an open service in an asylum in Tours during the war. As Toulouse himself insisted, however, the facility at Sainte-Anne was unique in several respects. It was by far larger than the others, it had a wider range of services, it did not mix open and closed services, it was a public facility (which accepted non-paying patients), and it was administratively autonomous, whereas many other open services were sections of hospitals or asylums. Most importantly, though, the service’s size, its Paris location, and Toulouse’s relentless efforts to publicize its successes to government officials and the public at large helped to make it a model for future institutions. Doctors lobbied for the creation of additional open services throughout the 1920s by highlighting the staggering miscalculations of healthcare administrators concerning populations of the mentally ill. According to these reformers, the number of interned individuals was rising steadily. Asylum populations had diminished during the war, but as men returned from the front, civilians came home from the provinces, alcohol consumption increased, immigrants flowed into France, and asylums resumed normal functions, their inpatient numbers rose.67 Though there was no postwar explosion of insanity, the return to prewar levels of asylum populations severely taxed existing institutions. Within just a few years of the war’s end, asylums were overcrowded, and their populations showed no signs of thinning. A variety of new plans surfaced to address the crisis. Some doctors and administrators favored the idea of transferring chronic patients from cities to provincial asylums. Administrators had attempted this strategy in the mid-

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nineteenth century, with only limited success.68 During the First World War, they again implemented transfers, then to protect aliénés from enemy forces and to make room in asylums for wounded soldiers.69 Administrators tried transfers yet again after the war, but provincial institutions soon became overcrowded as well. Other suggestions about how to resolve asylum overcrowding were offered freely by doctors. Henri Colin argued that the Seine department had to build new institutions, but it also had to better utilize its existing facilities.70 Antony Rodiet, a frequent writer on asylum overcrowding, recommended sending foreign aliénés back to their countries of origin.71 Russians chased from their country by the Russian Revolution, as well as Italians, Czechs, Poles, and others, who had come to France looking for work, were increasingly populating French mental institutions. And yet it was France that paid for their care. Rodiet reasoned that sending immigrants back to their home countries would facilitate more rapid treatment (since language problems often made it difficult to treat foreigners) and also reduce the financial and administrative burdens on French asylums.72 Toulouse and his colleagues insisted that the crisis of overcrowding could be solved with open services. They contended that the creation of open services could prevent the development of some illnesses and treat others; home treatment could keep even more people out of asylums; and the initiation of public education campaigns could further reduce the incidence of mental illness. Reformers also argued that open services could simultaneously reduce the costs of psychiatric assistance. As dictated by the asylum law of 1838, institutional fees were covered by the department when individuals requiring internment were unable to pay. Although the financial burden of interned aliénés had always been heavy, postwar economic troubles left departmental administrations with even less money for social assistance. Toulouse’s service promised to lighten the massive financial burden of psychiatric care by helping individuals avoid internment through a host of prophylactic programs and treatments. Furthermore, reformers asserted, open services could reduce the financial obstacles for many civilians seeking psychiatric assistance. The rising cost of living after the war meant that many troubled middle- and upper-class individuals could no longer afford private psychiatric care, which they might have been able to do before the war. Faced with the prospect of legal sequestration

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in public asylums, many of those disturbed individuals suffered at home. Open services, said advocates, provided a much-needed middle ground between the decrepit public asylum and the costly private sanatorium. Open-service advocates also noted that the economic instability of the postwar era was emotionally stressful for many French citizens. Still traumatized by the war, men and women were subjected to ongoing financial anxiety. Open services could help individuals for whom the stress of economic conditions necessitated psychiatric assistance. While open services promised to treat individuals, Toulouse and his colleagues repeatedly emphasized the benefits that these services would bestow on the nation as a whole. In addition to restoring the nation’s health, open services could contribute to the nation’s economic recovery by reducing patients’ time away from work. Outpatient services allowed patients to see a doctor and return to work the same day; the open service’s provision of active treatment reduced the length of costly inpatient stays; and efforts toward preventive care meant that French citizens did not have to interrupt their normal lives for psychiatric assistance. Despite persistent arguments for the potential benefits of open services, psychiatric reformers were only able to gain approval for a limited number of new services before the Second World War. For example, Octave Crouzon opened a neuropsychiatric service for observation and triage at the Salpêtrière in 1923 that bore striking resemblances to Toulouse’s service.73 Until then, the Salpêtrière had only neurology services and space for aliénés (which, as was noted earlier, was reduced in 1921). There were no services for intermediary patients afflicted with mild, non-neurological mental conditions that did not require internment. Like Toulouse, Crouzon believed that his service filled a void in psychiatric care: “Let us note, for men as for women, the high number of patients entering for petits mental syndromes . . . that is to say, troubles susceptible to cure or amelioration. This category of patient hardly found a place in the past in services of neurology and they were destined to the asylum.” 74 A similar center opened in 1926 at the Pitié hospital under the direction of Maxime Laignel-Lavastine. Once again, open-service advocates underscored the necessity of creating this center by emphasizing the social crises that followed the war. In approving the center, Paris health administrators noted that “The war years and the resultant economic difficulties have contributed to the development of a number of patients who are not true aliénés, but depressives for whom medical care is indispensable.” 75 Asylums were not the right place

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for these patients, nor were cost-prohibitive private clinics. Like Toulouse’s service, Laignel-Lavastine’s center had a dispensary to examine patients, treat them, or direct them to appropriate specialists. The Pitié’s new center, which was a neurological teaching ward, was meant to assist medical students in studying this “very particular category of patients.” 76 In addition to Crouzon’s and Laignel-Lavastine’s services, Henri Claude began a small open service in his twenty-bed teaching clinic at Sainte-Anne.77 An open service was also created at the asylum of Mont-de-Marsan, in Landes.78 And as mentioned previously, Henri Baruk created outpatient services, a small open service, and an experimental laboratory at Charenton–Saint­Maurice in the mid-1930s.

Public and Professional Opposition Toulouse and his service were well-known in France during the interwar period. By the 1920s, Toulouse had already gained a great deal of fame for his frequent newspaper articles. He also had achieved the dubious honor of being incorporated into a slang expression: French taxicab drivers of the era could be heard exclaiming, “Eh! Va donc chez Toulouse!” which might be the loose equivalent of “You belong in a madhouse.” 79 Unfortunately for Toulouse, his celebrity—and that of the Henri-Rousselle hospital—also made them prime targets for the scandal-hungry press. On January 15, 1933, Le Matin reported that an epileptic piano professor, who just a year before had been treated at Henri-Rousselle, had attempted to kill his wife with a razor and then take his own life.80 On January 26, 1933, Le Journal noted that a two-time murderer named Rambon had been treated previously at Henri-Rousselle, apparently without success.81 In an interesting reversal, the press, which had once maligned psychiatrists and their asylums for sequestering too many individuals arbitrarily, now played on age-old fears for public safety. In essence, the press insinuated that Toulouse’s open service had allowed too many dangerous, deranged individuals to escape proper incarceration.82 In the 1930s, Toulouse and his service began to be subjected to harsh criticisms from within the psychiatric community as well. Most of those criticisms stemmed from professional insecurities. Asylum doctors feared that by channeling curable patients into psychiatric hospitals, asylums would once again become custodial institutions for chronic patients. Doctors who remained at

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asylums would be cut off from the “medicalized” psychiatry of psychiatric hospitals and relegated to looking after incurables. To prevent the degradation of their specialty, asylum doctors made repeated attempts to evict Toulouse from his position of institutional power and to redirect psychiatry’s course away from his type of open service. Members of the Société médicale des asiles de la Seine tried to force Toulouse to retire when he turned sixty-five. The Association amicale des médecins aliénistes (a corporatist organization for alienists to which Toulouse belonged) later tried to exclude him from the association when he began to ease Georges Heuyer, a non-alienist, into his directorial position at Henri-Rousselle.83 Toulouse was also reproached for his high expenses, his alleged practice of holding some patients for observation against their will, and his “arbitrary” recruitment of doctors for his open service.84 In the end, neither Toulouse nor his alienist opponents were able to claim a clear victory. After Toulouse finally retired in January 1936, he was officially banned from the Association amicale. A competition was held for Toulouse’s position, but Heuyer—Toulouse’s choice—was passed over for Théodore Simon, a former alienist who had gained world renown by creating intelligence tests with Alfred Binet. When the Popular Front government lowered the national retirement age, however, Simon was forced out of his position, yielding his seat to Georges Genil-Perrin, a longtime collaborator and supporter of Toulouse.85

Legislative Hurdles Just as Toulouse failed to win over all of the members of his profession, he similarly failed to earn ample backing for open services among French legislators. Throughout the interwar period, Toulouse and his reform-minded colleagues hoped to revise the asylum law of 1838, which defined the types of psychiatric facilities and set forth voluntary and involuntary admissions procedures. Mental hygienists wanted to rewrite the law to include provisions for open services and psychiatric hospitals and to create a new type of psychiatric admission that would protect the rights of patients seen in open services without requiring them to be submitted to a formal legal procedure.86 Mental hygienists and reform-minded legislators encountered several obstacles to legislative change during the interwar period. The first was parliamentary politics. Constant changes in political power, a multiplicity of po-

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litical parties, rampant political opportunism, and a lack of party allegiance meant that securing sufficient support for any legislative project was frustratingly difficult. Given those hurdles, generating sufficient interest in the plight of psychologically troubled citizens was nearly impossible. Money was another major obstacle for the legislation of open services. Toulouse may have succeeded in convincing Seine administrators that his service would save them money by helping to reduce asylum admissions, but he and his colleagues had a much tougher time persuading parliamentarians to allocate precious funds to implement open services on a national scale. During the interwar period, few politicians realized the potential macroeconomic benefits of increasing government spending and expanding government projects during times of economic uncertainty.87 Rather than launching new initiatives, politicians—especially the conservative Moderates—tightened their fiscal belts. Efforts to implement open services on a national scale through new legislation might have fared better had Toulouse and his supporters had developed a means for those institutions to pay for their own administrative costs. For Toulouse, however, the financial costs of operating open services were small compared to the potential benefits they would bestow on the nation. He argued that because his psychiatric hospital was a hospital like any other, its patients should be accorded all of the rights and privileges of hospital patients, including the right to free assistance for those who could not pay. Ultimately, legislative projects to fund open services failed because reformers were unable to convince enough parliamentarians of the urgency of institutional crises and the importance of the plight of the mentally ill.88 Many of the projects to revise the law of 1838 were never even debated before parliament. This disregard for aliénés was a brutal fact of democratic politics: aliénés did not muster sufficient legislative interest because they did not constitute a significant number of votes. Consequently, their problems could always be shelved for another year. Unable to secure enough support in either house of parliament to pass a revision to the asylum law, reformers were forced to rely on the power of men in key government posts to issue reforming decrees and circulars, which did not require the support of the legislature. Fortunately, pro-reform politicians held government cabinet positions throughout the 1920s and 1930s. In February 1937, the minister of hygiene, Henri Sellier, specified that both public and private establishments created under the law of 1838 would be recognized as

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psychiatric hospitals.89 In October of that year, the next minister of public health, Marc Rucart, recommended reorganizing the departmental assistance for mental patients by creating mental hygiene dispensaries, instituting social services, introducing free services for observation and treatment, and modernizing closed services.90

Conclusion Open services did not accomplish all of the goals that Toulouse set for them. They do not appear to have erased the stigma of psychiatric care, nor did they completely eliminate critiques of psychiatric practice. They did not significantly reverse asylum overcrowding, and they certainly did not reduce the incidence of mental illness in France. While mental-health advocates won acceptance for open services in part because of the promise to treat patients who suffered from the psychological effects of war, there is little evidence that open services catered mainly to the psychologically traumatized. Nevertheless, open services do seem to have succeeded in providing care for a new clientele: mildly troubled individuals who could not afford private assistance and whose illnesses did not require them to be placed alongside incurables in public asylums. By offering psychiatric care to this otherwise neglected population, open services helped to extend the domain of psychiatry beyond the chronically ill to the near-normal. Toulouse’s open service saw a rising number of patients during the interwar period, as did the new services created at the Salpêtrière and Pitié.91 Total consultations at Toulouse’s open service more than tripled through its first decade, rising from 8,267 in 1923 (its first full calendar year of operation) to 29,710 in 1932.92 First-time consultations more than doubled, from 3,046 in 1923 to 7,960 in 1932.93 Admissions to the Henri-Rousselle hospital also rose substantially, from 742 in 1923 to 4,352 in 1932.94 Although Toulouse had meant to help patients avoid internment, many patients required it. Total asylum placements of patients seen in Toulouse’s service rose from 599 in 1923 to 2,148 in 1932.95 In 1930, the types of mental illness for which patients were interned varied widely, ranging from the neuropsychiatric sequels of epidemic encephalitis (1 percent of internments) to mania (6.5 percent), chronic delirium (12.5 percent), melancholy (16 percent), and alcoholism (22.5 percent).96 Despite the failings of open services, their implementation after the war must be recognized as a key moment in the history of psychiatry. Open ser-

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vices facilitated the transition from the custodial asylum to the medicalized modern psychiatric hospital. Along with England’s Tavistock Clinic and Maudsley Hospital and the “psychopathic” hospitals and outpatient clinics created by mental hygienists in several American states, Toulouse’s open service helped to introduce a new organizational structure and to define new modes of psychiatric assistance. In France, the continuing influence of Toulouse’s work was readily apparent after World War II. During the 1960s, departmental administrators reorganized psychiatric assistance around demographicgeographical “sectors.” In assembling these new services, administrators generally followed Toulouse’s model: each sector was to have a day hospital for psychiatric treatment and a mental hygiene dispensary, in addition to transitional housing and supervised workshops.97 The use of open services increased throughout the second half of the twentieth century. One historian has noted that as of 1989, 90 percent of psychiatric hospital admissions in France were processed through open services.98 The story of the creation of open services also underscores the important role of the Great War in the development of psychiatric practice. For decades before the war, psychiatric reformers had lobbied for change. Yet it was only the severe disruption of psychiatric facilities and the economic difficulties engendered by the war that helped convince departmental administrators that the open service was a concept whose time had come. With the environment ripe for change, the perception of a traumatized nation that psychiatric reformers energetically promoted helped to deliver their success. Finally, the implementation of open services provides important insights into the limits of psychiatric political power. By highlighting the war’s impact on mental-health institutions and by bolstering the perception of a traumatized population in their lobbying efforts, psychiatrists succeeded in garnering financial and administrative support for open services at the department level. And with that success, they were able to extend the reach of their practice to a new clientele. But they struggled, over the course of two decades, to secure support for open services and asylum law reform at the national level. Why? Because despite the attempts of psychiatrists to tie their cause to national rebuilding efforts, their clients continued to be swept under the legislative rug. Caring for outcasts and undesirables was not a high national priority.

Epilogue

Deschanel’s rest cure seemed to work. In late December 1920, he left Malmaison and pursued a fast reintegration into public life. A Senate seat became vacant in the Eure-et-Loir region (the area Deschanel had served since 1885 as a deputy), and he entered his name on the ballot. In January 1921, he was elected. His term was short, however. Deschanel died in April 1922 from pneumonia.1 Conjectures regarding Deschanel’s neuropsychiatric illness continued for decades. Doctors and historians reexamined the former president’s symptoms and behaviors, and they entertained new hypothetical diagnoses, including neurasthenia, syphilis, Alzheimer’s disease, and “frontotemporal dementia,” among others.2 In 1948, Benjamin Joseph Logre, who directed the Paris Infirmerie spéciale and was a medical expert in legal cases, published his professional opinion on Deschanel in the French daily Le Monde.3 Logre suggested that Deschanel’s fall from the train could be attributed to a syndrome that Logre named after a Homeric character, Elpenor. According to the original tale, Elpenor had become drunk and had slept in an unfamiliar place—the roof of the temple of Circe. When he awoke, he was disoriented and fell, breaking his neck and dying. Logre argued that like the mythical character, Deschanel was in a somewhat altered state when he went to bed on the evening of May 22. He was depressed and tired, and he had taken a hypnotic. When he awoke to open the window, in unfamiliar surroundings, he lost his balance and fell. In 1950, Logre reiterated his opinion in a medical certificate issued at the request of Deschanel’s descendants.4 Like the president’s doctors had done in 1920, Logre blamed the excessive fatigues and stresses to which Deschanel had been exposed in the years preceding his accident both for the accident and his subsequent illness. Deschanel’s problems, according to Logre, were not due to any inherited defects:

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President Deschanel, after having enjoyed until then excellent physical and mental [morale] health, experienced, as a consequence of the emotions and the fatigues suffered during the war, a depressive crisis that, having commenced at the beginning of his stay at the Élysée, lasted close to two years. It was a question of a state of sadness, with fatigue, of insomnias and various nervous troubles that rendered it at once difficult and uncomfortable to perform his important duties. His mental trouble, as it is usual in these depressive states, essentially resulted in an emotive and sensitive state, in no way attacking reasoning abilities, in particular his memory and his judgment.5 According to Logre, Deschanel suffered from something akin to a “breakdown” (Logre used the English term) or neurasthenia. The breakdown was a transitory depressive state without antecedent, which had no effect on his intellectual faculties. Perhaps most importantly for the relatives who had requested Logre’s evaluation, the doctor maintained that Deschanel’s illness in no way could have been transmitted to his descendants. Either the hereditary model of mental illness was finally losing its grip on psychiatry or, more likely, Deschanel’s celebrity status helped protect him and his descendants from being labeled as hereditarily scarred.

Remembering: Years of Traumatic Symptoms The neuropsychological effects of the war did not end in 1920. Years after the war, veterans and civilians continued to display seemingly war-related problems. But as the years rolled by, doctors concluded that these disturbances were related less to the trauma of initial wartime shocks and more to a range of other factors, from physical problems to a quest for larger pensions. Jean Ch., a thirty-three-year-old teacher, had been commotioned at Verdun in 1917.6 Knocked unconscious, he was transported first to an emergency station and then to an evacuation hospital, where he regained a sense of his surroundings some nine hours after the explosion. Two days later, he was sent to a hospital in Vichy, where he remained for a month. Although he complained of persistent headaches and mild dizziness, he was sent back to the front. Jean had been a “gay” and “courageous” under-officer before his injury, but his superiors noted that after his return to battle, he was taciturn and worried.7 He lost all authority over his men and was frequently found crying. He complained of continuous, violent head pains and painful heart palpitations.

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Useless on the front line, Jean was reassigned to the auxiliary. In a medical depot, he eventually regained his equilibrium, but he continued to complain of headaches and dizziness through the end of the war. After the armistice, Jean found a job as a teacher in a commune in his home department. For three years, he fulfilled his duties perfectly, yet he was often irritable. The lack of discipline exhibited by his students angered him, sometimes triggering bouts of “light violence,” as he later admitted to doctors.8 After being reassigned to a new post, he complained of general fatigue. Moreover, he frequently forgot the hour of his classes and increasingly neglected his responsibilities. He soon began to attract hostility from the commune for his unstable and sulky temperament. Following a reprimand from his superior, Jean gave up teaching and decided to farm a small plot of land where his mother lived. Yet even in that peaceful setting, he could not escape recurrent feelings of anxiety and the memory of war. Rather than working, he passed much of his time with “childish” activities, such as playing with the dog and cat. He cried often, lamenting his situation and acknowledging his deterioration. At night, the slightest noise made him anxious. The chime of a clock or the bark of a dog in the street could cause him violent heart palpitations. Sleep offered little solace. He had persistent nightmares in which he revisited the war. With his symptoms getting worse, some ten years after his initial commotion, Jean took a friend’s advice and went to the discharge center of his town for a medical consultation (and probably to make a new pension claim). In addition to his persistent feelings of anxiety and his childish behaviors, Jean showed signs of short-term memory loss. He had to keep track of mundane daily acts on a note card or risk forgetting them; he often forgot recent conversations. Though he was seen three times by the doctors, he could not remember their names or the route to their office. Jean’s doctors found it difficult to communicate with him. He often interrupted them to provide “infantile” details. During his visits, he would fiddle with ornaments hung from the door while asking strange, “indiscreet,” and “naïve” questions. Sometimes he was euphoric and teasing, but always “bizarrely familiar.” When he was asked about his professional setbacks, he broke into tears.9 Jean’s doctors were unable to find any abnormal neurological signs. The results of a lumbar puncture were negative, a neurological exam showed nothing, and Jean was perfectly sober. Despite the absence of physical signs, Jean’s doctors were able to obtain for him a 60 percent disability pension.

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According to the doctors Maurice Pignède and Paul Abély, who published Jean’s case in a neuropsychiatric journal in 1930, Jean’s lingering, post­traumatic symptoms were not uncommon among survivors of serious injuries or accidents. Survivors like Jean often suffered from extreme fatigue, attention deficits, immature behavior, and amnesia. They also exhibited irritability, impulsiveness, affective instability, immaturity, emotional instability, and a tendency toward neurasthenic or cyclothymic states (that is, mood swings between elation and depression). Like Jean, many patients with post-traumatic symptoms had trouble keeping their jobs. According to Pignède and Abély, this collection of symptoms was always associated with physical signs, such as headaches and dizziness. Pignède and Abély believed that Jean’s troubles, and those of similar cases, were the result of a physical, neurological injury— probably damage to the prefrontal lobe.10 Why didn’t Jean’s doctors consider the role of memory in his ongoing illness? Pignède and Abély might have been correct in attributing his primary symptoms to physical injury. Still, Jean also suffered from recurrent nightmares about the war as well as persistent nervousness and anxiety. Couldn’t it have been possible that the traumatic memory of the war at least exacerbated his neurological problems? In contrast to today’s posttraumatic stress disorder diagnosis (created by a Freudian-influenced American psychiatric community), the notion that memory—or a disturbance of memory—could play a role in the development or prolongation of a neuropsychiatric disorder was anathema to most French doctors during and after the war. There were at least two problems with the idea of memory as a causal factor in illness. First, it opposed the prevailing etiological model, which emphasized the role of inherited defects and acquired weaknesses in the cause of mental illness. As Freudians would have it, traumatic memory might occur in just about anyone; hence, illness could develop in otherwise healthy individuals. Yet French doctors continually found that neuro­ psychiatric illnesses tended to develop mainly in those who were predisposed to them. The acceptance of traumatic memory as a possible triggering factor would have required either a paradigmatic shift in neuropsychiatric thinking or at least the conclusion that memories would cause disturbances only in certain individuals. Second, the idea of traumatic memory as a causal factor in illness threatened the perception of an increasingly scientific, medicalized psychiatry. The mainstream of French psychiatry refused to promote models of illness that did not ultimately connect the mind to the body. Functional illnesses, French

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doctors had decided, were false illnesses since there seemed to be no physical cause for them. To many doctors, the ideas of Janet, psychoanalysts, and more philosophically oriented psychologists did little to advance the science of psychiatry, which, like neurology, was more interested in physical causes of disease than purely psychological ones. It would not be correct to conclude, however, that the neuropsychiatric community neglected the study of memory entirely. During and after the war, neurologists and psychiatrists conducted numerous studies on amnesia among soldiers. They examined the causes of amnesia and its relationship to other components of cognitive functioning. In addition, experimental psychologists, many of whom were medical doctors, were also interested in memory. But their focus was more on the process of how memory operated in normal individuals. With the exception of Janet, neither experimental psychologists nor the medical doctors investigating amnesia studied the ways in which memory itself might be a trigger for illness. That was the domain of psychoanalysts. The exclusion of traumatic memory as a possible triggering factor for mental illness shows the strong drive by psychiatrists to attach their specialty to medicine proper. At a time when France seemed fixated on remembering the war, psychiatrists wore blinders.11 The introduction of traumatic memory— or any other nonmedical conception—to psychiatric thinking was staunchly opposed by them. The small number of psychoanalysts in postwar France were willing to consider the role of traumatic memory in the development of neuropsychiatric illness, but those psychoanalysts (nearly all of whom were psychiatrists) faced steep obstacles in gaining acceptance among their neuropsychiatric peers for this allegedly unscientific, Germanic, overly sexual, derivative, and error-prone psychoanalytic ideology.12 While Pignède and Abély were not willing to consider the possible role of traumatic memories of war in Jean’s case, they were at least willing to connect his lingering postwar problems with his wartime physical injuries, thereby qualifying him for compensation. In contrast, René Targowla, a frequent collaborator of Édouard Toulouse, found that those types of connections often failed to hold up to scrutiny.13 Targowla found no shortage of veterans who claimed to experience disturbances related to their original commotions. But for him, those disturbances had little relationship to the rattling that soldiers experienced during the war. “Cr . . . Alphonse” was commotioned by falling pieces of a building in 1915, though he returned to the front after several weeks of hospital rest.14 Back in

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the field, he was wounded several times and twice received citations for his outstanding fighting. In 1933, some fifteen years after the war ended, he requested and obtained a 10 percent disability pension for headaches, vertigo, memory troubles, intolerance to noise, and irritability, all allegedly related to the 1915 commotion. A year later, in March 1934, the rate of his invalidity was raised to 25 percent because of the accentuation of his troubles and his inability to find a suitable job. He suffered from hyperemotivity and irritability, and he occasionally fell as a result of his vertigo. Targowla had found similar symptoms in a number of veterans, with a range of ages, military experiences, and social conditions. All had been commotioned during the war and had first suffered symptoms that rapidly disappeared in the weeks or months immediately following the injury. Then, after a long latency period (from six to eighteen years), subjective troubles reappeared. After evaluating eighty-nine such cases, Targowla concluded that the majority of patients’ post-traumatic symptoms were not in fact lingering sequels to physical trauma, but rather “banal” subjective troubles that were often related to other problems, including the effects of alcoholism, syphilis, hepatitis, or arteriosclerosis.15 According to Targowla, patients incorrectly attributed those symptoms to their wartime injuries, basing the association on the perceived resemblance of their present symptoms to those they suffered after their original commotions. According to Targowla, many men made those associations purposefully, hoping to raise the rate of their pension by presenting disturbances related to the war. Targowla noted that Alphonse, who applied for a pension increase in August 1934, was found to have cerebral vascular sclerosis, arterial hypertension, and an irregular heartbeat. In 1935, he was hospitalized for an episode of confusion, at which time doctors also found alcohol in his urine. Targowla insisted that these physical and behavioral elements were to blame for the patient’s recent symptoms, not the commotion he experienced twenty years earlier.16 Moreover, Targowla believed that Alphonse was clearly hoping to connect his current problems to his wartime injury in order to receive a more substantial pension. He noted that Alphonse had a long history of applying for pension increases. He had applied in 1921, 1928, and 1930 for compensation related to other problems. In none of those applications did Alphonse mention postcommotional disorders. For Targowla, those previous omissions called into question the legitimacy of the patient’s current claims. By the mid-1930s, then, doctors such as Targowla seemed to believe that

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the war was over. The men and women who had suffered acute neurological or psychiatric disturbances during the war had been cured, or at least their fleeting crises had passed. The predisposed who developed long-term, durable mental illnesses over the course of the conflict had been integrated with the chronic cases in mental asylums. Even the doctors who believed that some psychological disturbances might develop only after a latency period did not think that the latency period could extend for decades after the war. Thus, the veterans who complained of lingering neuropsychiatric problems were treated with skepticism by doctors, who believed that they were merely trying to increase their pensions. Because most doctors did not count traumatic memories as a strong potential cause for illness, they concluded they had seen all the men who would develop disturbances as a result of the Great War. Unfortunately, another war was just around the corner.

A New War On the eve of a new war in 1939, French doctors were once more forced to contemplate the possible effects of military and sociopolitical upheavals on the mental health of soldiers and civilians. Like their earlier counterparts, this generation of doctors seemed willing to consider the roles of emotions and situational factors in the genesis of mental disturbances. But their observations and statistical analyses revealed what many of their predecessors had concluded: the stresses of war were the direct cause of mental problems in only a small number of individuals, and most of whom were predisposed to illness. Not long after war was declared, the Société médico-psychologique, which had published book-length articles on the effects of the Franco-Prussian War on civilians during the late nineteenth century, collected reports on the impact of current events on mental illness. At the society’s December 1939 meeting, the doctors Pierre-Adolphe Chatagnon and Simone Jouannais presented their observations from the Maison-Blanche asylum.17 They noted the inherent rationality of assuming that great cataclysms would foster the development of psychoses and psychoneuroses. They also contended that Maison-Blanche (a women’s asylum) provided an excellent vantage point from which to study the effects of recent events. Though the Great War should have taught them (and other doctors) that men were no less susceptible to psychological trauma than women, Chatagnon and Jouannais nevertheless believed, as most people in that era did, that women tended to respond to psychic and physical stimuli more easily and more rapidly than men.

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Chatagnon and Jouannais found, however, that of the eighty-two patients who entered Maison-Blanche between September 1 and December 1, 1939, only one case was directly tied to the war. A forty-six-year-old woman was admitted on September 3, 1939, in an anxious state with hallucinations, an active, dreamlike delirium, and nightmares. She had left her accounting job on August 30, falling ill quickly. After her cure, she described her illness: For several nights before I had slept poorly. I was having nightmares, me, who ordinarily has a very calm sleep. I had a premonition about a next war or a similar cataclysm since the general conversation was commenting on the events. I had difficulty eating meals, an anxiety gripped me by the throat and I could not swallow anything. The night of August 31, I was very afraid when going to close my door before going to bed, I had noted that at the same instant someone was locking the security bolt from the outside. I tried to open the door. I heard some noise in the staircase, then from the floor above. I was panic-stricken, and, thinking of a possible burglary, I left my apartment to seek refuge with some friends living close to me. I arrived at their place close to 10 p.m., I explained to them my panic, I had a fever and I spoke incessantly of the imminent war, from Berlin, from Moscow. . . . [Her friends gave her a tablet to calm her.] Maybe it was the effect of this calming pill, but moments later I experienced some hallucinations, then I slept a little, I had sensed then that the fever was coming back, all the noises from the street seemed to be amplified, I was weak and completely exhausted, my brain alone was working, I had to talk or cry.18 At Maison-Blanche, she exhibited motor agitation, psychic excitation, and anxious fears. She was afraid for her life—afraid of bombs. Her terrifying hallucinations were deemed to be of a hypnogogic (pre-sleep) type, with associated phases of confusion. Nearly one month after entering the asylum, her agitation ceased and regular sleep returned. According to her doctors, she was totally cured after an additional month, leaving Maison-Blanche on October 30. The symptoms experienced by another woman also appeared to be caused solely by the war, but according to Chatagnon and Jouannais, they could be explained by other factors. This women, forty-seven years old, was admitted to Maison-Blanche in late August 1939. Like the first patient, she too had started to suffer from nightmares related to her fear of an impending war. Still, this woman had a number of predisposing factors to mental disturbance. First, she

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had experienced a psychological trauma years before. Married in 1913, she had lost her husband in the First World War less than a year later. In addition, her temperament seemed primed for troubles. Chatagnon and Jouannais reported that she was emotive, impressionable, and hypersensitive. They also noted that she was nearly menopausal—a fact that probably suggested an increased susceptibility to emotivity. As the final nail in the etiological coffin, her family history rendered her predisposed to illness. Her paternal grandfather was an alcoholic, and her brother had committed suicide by hanging. According to Chatagnon and Jouannais, this case was more typical of the ostensibly warrelated cases of psychological trauma that appeared in 1939. Predisposition to illness played a much stronger role in the development of disturbances than current events.19 Of the nearly one thousand patients already hospitalized at Maison-Blanche in 1939, Chatagnon and Jouannais noted that barely fifteen were affected by recent events. Some delirious patients reported ideas that were connected to international tensions; meanwhile, three cases of melancholy and one case of alcoholic confusion were influenced, though indirectly, by the declaration of war. Nevertheless, the doctors argued, the routine existence of daily hospital life remained relatively undisturbed by outside events, except in patients who already had histories of emotivity.20 Several doctors responded to Chatagnon and Jouannais’s paper at that December society meeting with theoretical arguments on the effects of war on mental health and anecdotes from their own practices around the French capital. While many respondents used their time to repeat well-worn conceptions of war neuroses found in soldiers, François Achille-Delmas focused on the impact of upheavals on civilian populations. He argued that wars could in fact trigger psychological illnesses in civilians, especially at the outbreak of the conflict. Traumatic events could, for example, reawaken bouts of mania and melancholy in patients who suffered from them only intermittently. AchilleDelmas noted that in 1914, he had found a surge of melancholics and maniacs during the first eight days of that conflict. He noted that a similar phenomenon had occurred in the fall of 1939. From the declaration of war in September 1939 to the December society meeting, there had been little actual fighting on the Western Front. But according to Achille-Delmas, anxiety and depression were rife among civilians during that period of “phony war.” For example, an intermittently depressed Polish woman whom Achille-Delmas frequently saw suffered a new bout of depression—not surprisingly—on the day of the Polish

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invasion by Germany. Though the number of aliénés might not increase during war, said Achille-Delmas, the number of cases of mania and melancholy certainly did.21 Jacques Vié, another doctor from Maison-Blanche, could connect only a few cases to the events of 1938 and 1939.22 Vié observed that some illnesses erupted at the first signs of war. In 1938, for example, a twenty-five-year-old woman with tuberculosis was admitted to Maison-Blanche for emotive delirium following her evacuation first from Ardennes and then from Lille to Paris. Most illnesses triggered by the threat of war, however, were not durable. A fortynine-year-old widow being treated at the Saint-Antoine hospital for a mitral malady became mentally confused and expressed anxiety that her fifteen-yearold son would be taken away. But her mental troubles eventually dissipated. Vié noted that of the forty-six patients admitted to Maison-Blanche from September 1 to November 20, 1939, recent events influenced the appearance of psychosis in only two cases and were occasional (or indirect) causes of illness in only six. In thirty-eight cases, the events apparently made no difference. Henri Beaudouin discussed the effects of war on more severely disturbed individuals.23 Since mobilization, 120 patients had entered the Infirmerie spéciale, only twelve of whom had illnesses that could be connected to the war. Like other doctors, Beaudouin noted that delirious patients often incorporated current events into their states. One twenty-three-year-old woman, who entered the Infirmerie on September 5, 1939, said she wanted to see the president of the republic so that she could be put in touch with Hitler. She had experienced a similar episode the year before, during the period of international tensions of 1938. Another woman, forty-three years old, came from Cannes to Paris with the goal of being presented to the État-Major for service. When she explained her quest to a policeman, she was taken to the Infirmerie. Beaudouin also reported the cases of patients who demonstrated less delusional, more normal reactions to current events. For example, the nerves of several individuals were rattled by the nighttime alerts of 1939. A seventyfive-year-old widow was found to be in an excited state with delirium when she was arrested for refusing to extinguish her lights during an alert. Others became anxious at the announcement of war and the subsequent disruption to their lives. A thirty-seven-year-old woman developed anxious melancholy and suicidal ideation following her evacuation from Brittany. As Paris doctors observed civilian cases, the army once again established specialized centers to deal with the possible influx of soldiers with psychiatric

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and neurological problems. Given the speed at which the Germans dispensed with the French army in 1940, it should not be surprising that relatively few cases of war-induced neuropsychiatric disturbances appeared among French troops. The culture of hysteria that developed during World War I, which brought together predisposed men, a diagnostic and therapeutic assembly line geared toward identifying malingerers, and an environment rife with emotional and physical triggers, never had a chance to form.24 It was too brief a war; moreover, it was a different kind of war. Unlike the First World War, in which men were hunkered down in trenches for months at a time with shells exploding incessantly over their heads, the short military confrontation between the French and Germans in 1940 was a war of movement—even though, for the French, much of that movement was in retreat. Consequently, men did not have as much time to ruminate about their fears as did soldiers during the previous war. Nor did they suffer the ongoing physical fatigue that had contributed to the emotional collapse of so many World War I soldiers. While some French troops did suffer psychological strains during the spring of 1940, not many of them did. The brief military engagement drew by far fewer men into battle than the First World War. With fewer men engaged over a shorter period of time, the total number of soldiers who succumbed to psychiatric and neuropsychiatric illnesses was bound to be much lower than the total from the previous war. Still, seemingly war-induced neuropsychiatric disorders did not disappear. Henri Baruk manned a neuropsychiatric center in Reims, where he saw among troops several cases of classic hysteria, in which soldiers exhibited the bizarre contortions and contractures that had characterized the disease in Charcot’s day.25 Most of those patients had developed hysteria while recovering from physical wounds. Like doctors in the previous war, Baruk underscored the necessity of employing neuropsychiatric specialists to attend to soldiers’ peculiar disorders. Those specialists should exude an air of confidence and authority over their patients. He noted the potentially dire consequences of sending in less-thanconfident general practitioners: I was given a ten-day leave, and the care of my patients was handed over to a general practitioner who, though an excellent physician and very scrupulous, was not used to treating nervous disorders. I gave him advice and reassurance, without much success I was to discover later, for he tackled his new duties with a bad case of the jitters. It so

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happens that patients with nervous disorders are hypersensitive to the moods of those who come near them. From the very first day that their new doctor took over, the atmosphere changed. They became extremely agitated, and some of them relapsed into fresh crises. Nervous disorders which had been minimal and isolated became general and serious; the contagion spread and accelerated.26 How should an expert treat these men? Baruk used the same methods he had at Charenton–Saint-Maurice asylum: “Active psychotherapy based on trust, understanding, and friendship, along with assiduous work.” 27 Though Baruk had been a student of Babinski, his method was a kindler, gentler persuasion: I approached the first man and told him who I was and promised that I was going to make him well. I continued to talk to him calmly, reassuring him as though he were a child who had been frightened by a bad dream in the night. I began to massage a spot on his body gently with my finger, explaining that as I touched him all his terror would evaporate. Soon I began to feel the muscles relax, the body lose its rigidity, and then I saw a look of intelligence return to the half-conscious face. In half an hour normality had been restored to the whole ward. . . . I had not worked a miracle. I had merely put into practice the guiding principles of the method my teachers had taught me.28 For nations who endured a longer military conflict, shell shock yet again posed challenges for doctors. Despite the efforts of psychiatrists, neurologists, social scientists, and military administrators to screen out potentially susceptible men during the incorporation process and to better prepare for the shell-shocked combatants who would inevitably appear in military hospitals, soldiers from the United States, Britain, Canada, and Germany continued to experience war-induced disturbances.29 Interestingly, those soldiers displayed subtly different types of symptoms than their World War I counterparts. Relatively few of the soldiers from World War II experienced classical hysterical contractures and paralyses. Instead, according to doctors, many soldiers seemed to exhibit symptoms with greater symbolic value. Men who were required to give orders developed aphasias; watchmen went blind; radiomen went deaf.30 Doctors also found a large number of stress-induced somatic disorders during episodes of particular psychic and physical duress. British troops

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developed ulcers after the retreat of Dunkirk; Germans suffered an epidemic of hypertension during the siege of Stalingrad. Finally, doctors diagnosed more cases of “battle fatigue” and “battle exhaustion”—categories that often connoted mental exhaustion but probably resulted more from the extreme physical exhaustion experienced by soldiers as they marched, for example, in columns with heavy packs across North Africa.31 These subtle shifts in symptomology resulted from changes in the way war was waged, but they also reflected changes in patients’ and doctors’ conceptualizations of illness. Like the soldiers of the previous war, many World War II combatants expressed psychological stress in forms that they (unconsciously) believed to represent real, physical illnesses. Meanwhile, psychiatrists, many more of whom embraced psychoanalytic ideology than in the previous war, were apt to see symbolism in their patients’ symptoms and “conversions” of psychic conflicts in soldiers’ physical complaints. Doctors identified more stress-induced physical illnesses because they were now more likely to believe that anxiety could play a role in the development of physical troubles. In any case, most of the new varieties of shell shock that appeared during World War II were medical and military challenges for other nations, not for France. By mid-1940, the French military was defeated, and doctors were released from duty. Until psychiatric centers were established again in 1944, first in North Africa, those specialists did not play significant roles in the official war effort.32 More accurately, there was no official war effort in which they could play roles.

Occupation Despite the best efforts of psychiatric reformers from the interwar period, large numbers of men and women remained stranded in dirty, overcrowded public institutions during the occupation. As Max Lafont has shown, the neglect of citizens interned in mental hospitals (as they were by then called) reached a new peak during World War II. With staples scarce in France, administrators restricted food and heat rations to these institutions. The ultimate consequences of the restrictions were the deaths of approximately forty thousand psychiatric inmates during the war.33 Although tuberculosis or other illnesses were often listed as the official causes of death, malnutrition was an instrumental factor in the acquisition of fatal illnesses. Were some of the psychiatrically disabled veterans of the First World War

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among those who died? That was probably the fate of Anthelme Mangin—the living unknown soldier who went unclaimed throughout the interwar period. As for the others, we do not yet know for sure. It would have been a particularly tragic end for those men, who, according to their interwar-era advocates, had sacrificed their sanity for the good of their nation. After the liberation of France in 1944, the French faced another period of psychological recovery. Yet the emotional strains of that period were qualitatively different than those of the interwar era. After World War I, men and women struggled to cope with sadness caused by the loss of their loved ones, as well as anxiety triggered by economic uncertainty. After World War II, the French had to come to terms with their individual and collective roles in the occupation. Accusations of collaboration and the propagation of myths of resistance created new types of tension, anxiety, and depression. Although memories of the occupation have been discussed in psychological terms by historians,34 no one has yet studied whether French men and women sought assistance from psychiatrists to cope with their guilt. Such a study would provide an important complement to the existing historiography on the memory of Vichy France.

Psychiatric Change Less than a decade after liberation, the first of several waves of change swept over the French psychiatric profession. In the early 1950s, the introduction of psychopharmaceuticals revolutionized psychiatric practice in France and around the world.35 Psychiatrists at the Paris school of medicine who were teaching and practicing at the Sainte-Anne asylum made important contributions to early psychopharmaceutical research.36 Momentarily, French doctors were once again at the center of European (and international) psychiatry. In the 1960s, the psychoanalytic movement, which had remained marginal in France during the 1920s and 1930s, finally took hold. Jacques Lacan played a primary role in bringing psychoanalysis to more French couches and in extending the influence of psychoanalysis beyond the couch, into French culture.37 Psychiatric institutions also experienced important changes in the decades after the Second World War. As mentioned in the previous chapter, administrators decentralized the psychiatric admissions process in the early 1960s, abandoning the model in which patients were examined at a single admissions bureau and then distributed among departmental institutions. Psychiatric care

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was thereafter organized around demographic and geographic sectors, with each sector including elements that recalled both the World War I organization of psychiatric centers and the open service built by Édouard Toulouse in Paris. The asylum, which had disappeared in name in 1937, disappeared in practice after World War II (even if some would argue that mental hospitals inherited many of the problems of asylums). The advent of psychopharmaceuticals (which helped doctors release many patients from the purgatory of chronic wards), along with repeated critiques leveled by the anti-psychiatry movement and the passage of new social-assistance legislation all contributed to the asylum’s dissolution.38 Yet it was the memory of France’s occupation during World War II that brought the asylum to its end. The embarrassing, fatal neglect of psychiatric patients during the war spurred psychiatrists to abolish a system that had so obviously failed to care for the mentally ill. The history of psychiatric reform in the wake of the death of so many mental patients—a history that was begun by Max Lafont in 1987—deserves to be continued. It could reveal a unique perspective on how the French faced their Vichy past.

Historical Diagnostics In 1980, after years of lobbying by advocates for Vietnam veterans and by other victims’ rights groups, American psychiatrists officially introduced a diagnostic term that we might be tempted to apply, in retrospect, to some of the French citizens who suffered psychological disturbances as a result of the First World War: posttraumatic stress disorder (PTSD).39 Today, PTSD is defined as a type of anxiety disorder that can follow an event (or events) in which an individual experienced or witnessed a serious physical threat or emotional trauma and responded with intense fear, helplessness, or horror.40 Individuals with PTSD re-experience the trauma through dreams or flashbacks; they avoid stimuli associated with the trauma and demonstrate psychological “numbing”; and they show signs of increased arousal, such as loss of sleep, irritability, or exaggerated startle responses. For disturbances to be classified as PTSD, they must last for more than one month and impair social, occupational, or other areas of functioning.41 Individuals with PTSD often suffer from depression, anxiety, or substance abuse as well. Like the First World War’s neuropsychiatric disorders, the etiology of PTSD has been cause for debate among psychiatrists.42 Researchers agree that the

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trauma of war and sexual assaults can trigger PTSD, but they differ about the process by which PTSD develops within individuals. Biological, psychoa­ nalytic, cognitive, and behavioral models have all been proposed, although the psychiatric community has not settled on a single one.43 Researchers also have tried to explain why some individuals succumb to the disorder while others do not. To the extent that there is consensus on the issue, many psychiatrists have concluded—just as French doctors did in reference to the war-induced disorders of the First World War—that individual factors, such as familial or constitutional predispositions to psychiatric illness, often predict who will develop PTSD after a traumatic event. Researchers also differ as to the proper treatment for PTSD. Psychotherapies have been proposed, including cognitive­behavioral therapies that aim to manage anxiety and correct harmful cognitive functioning.44 Yet increasingly, pharmacological options have shown promise. Doctors now treat PTSD with drugs that are also used to counteract depression and anxiety.45 Would PTSD have been an accurate label for French men and women suffering from the psychological effects of the First World War? The historian Elaine Showalter argued that disorders such as shell shock, Gulf War syndrome, and PTSD are all subtle variations of hysteria—a protean disease with variable symptomology.46 It is true that the triggers and symptoms of many disturbances experienced by French soldiers match current definitions of PTSD. But some of the soldiers who were diagnosed as hysterical, pithiatic, commotioned, or confused would probably receive other diagnoses today, ranging from depression and anxiety to schizophrenia (a typical catch-all category). Some may have suffered from true organic conditions that wartime doctors were unable to identify. Others may have been demonstrating relatively normal, sane reactions to insane conditions. (Is unconsciously planning a peaceful way out of fighting necessarily pathological?) Still others may very well have been true malingerers who deserved discipline rather than medical treatment. As for the civilians who lost loved ones or worried about earning a living in difficult economic times, PTSD is probably not an accurate label. Many of those men and women would be better diagnosed with forms of depression (as many were at the time) or different kinds of anxiety disorders (a category that had not yet gained popularity in interwar France). PTSD might, however, be applied to civilians who broke down after bombings of cities or who relived the horrors of facing the enemy in the war zone.

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A major problem in applying a retrospective diagnosis is that it ascribes a permanence to diagnostic categories. By claiming that an early twentiethcentury French soldier truly had PTSD suggests that there was, is, and forever will be some true, natural category called PTSD, even if doctors at the time had yet to discover it. Showalter’s interpretation suggests just such a permanence to a disease entity, though she allows for changes in the label applied to a specific disease. But as the discourse over war-induced disturbances shows, disease categories are constructed through an interplay of many factors. The symptoms expressed by individuals and the diagnoses and treatments applied to them by doctors are too closely tied to specific professional, political, economic, social, and cultural contexts to allow us to apply today’s categories to yesterday’s patients.

Legacy and Meaning It would be too great a leap from the evidence presented here to argue that the psychological effects of the Great War played a significant role in France’s military and political collapse of 1940. In the first place, this study focuses only on the effects of trauma experienced by individuals who interacted with the medical profession. It does not investigate the sorts of sadness and anxiety experienced by the majority of French men and women—“normal” emotions that were endured without psychiatric treatment. Nor does this study attempt to characterize France’s collective trauma or to evaluate the broad effects of collective trauma on French society. Ultimately, the role of any lingering psychological trauma that the French suffered will have to be assessed in concert with the full range of other factors that contributed to France’s defeat, including the failures of the French government to modernize the army and to address the threat of Nazi Germany earlier, the inability of diplomats to secure and strengthen alliances, the important consequences of declining natality, and the military errors of the High Command in waging the battle of France.47 Only then can the importance of France’s alleged collective psychological trauma in the events of 1940 be fully evaluated. It is clear from this study, however, that by the time World War II was declared, the psychological effects of World War I still played important roles in the lives of many individuals. French women still trickled into closed asylum services throughout the 1930s with problems they claimed were related to the

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Great War. At the same time, many other civilians and former soldiers continued to suffer the social, legal, and economic effects of psychiatric labeling and institutionalization. Psychiatrically disabled veterans, for example, remained sequestered in departmental institutions far from their families. Despite the persistent efforts of veterans’ advocates, those interned men saw only small improvements in their psychiatric care and financial situation by the end of the 1930s. Consequently, many ex-servicemen continued to be housed alongside lost causes while their families struggled to make ends meet. Veterans who had suffered from milder, allegedly war-induced disturbances had to endure their ongoing psychological pain with little financial or medical assistance from the state. While the governments of other countries awarded pensions and provided specialized psychiatric care to soldiers with functional illnesses and other disorders, France largely continued to equate these men with malingerers. France may have succeeded in avoiding the financial and administrative burdens that other states endured as thousands of their ex­servicemen applied for war-neurosis pensions; but clearly, in denying privileges to many psychologically traumatized veterans, France did not act in their best psychological or economic interests. One might argue, then, that this history of psychological trauma above all highlights further examples of the Third Republic’s failures to address the pressing problems of the French nation. Just as the French government during the interwar period failed to confront international crises, modernize the military, and rescue a faltering economy, it also failed to provide adequate psychiatric care for its traumatized citizens. Parliamentarians failed to endorse legislative projects and—except in a few important cases—refused to support initiatives proposed by medical reformers that might have enabled French citizens to receive the psychiatric care they needed. While it might be too much to argue that those additional governmental failures contributed to France’s 1940 defeat, it is certainly reasonable to conclude that they ultimately delayed the psychological recovery of many individuals. Doctors are not free from blame in this interpretation of events. It was wartime neurologists and psychiatrists who set the standards for dealing with neurologically and psychologically disturbed soldiers. Neurologists insisted that hysterics, who were for them tantamount to shirkers, be refused all special privileges. Psychiatrists, meanwhile, facilitated the rejection of many pension claims by arguing that many psychological disturbances had, in some form, predated the war. In contributing to the wartime revision of the pension

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law and its disability schedules, neurologists and psychiatrists dealt their patients additional blows by refusing soldiers and their families adequate compensation for war-induced mental disturbances. Édouard Toulouse argued for radical changes in psychiatry that would have created new institutions to treat acutely afflicted patients, including the psychologically traumatized; but Toulouse met stern resistance from asylum doctors who, fearing they would become second-class citizens in psychiatry by being relegated to chronic cases, placed their own professional concerns above the welfare of their patients. This book has shown that in attempting to raise the status of their professional specialties, doctors repeatedly failed their patients. Certainly, this history is filled with failures. But to view it as only a history of failures is to make the mistake of ending the story with the Second World War. Yes, by 1939, psychiatrically disabled veterans and civilians were still largely ignored by their country, and doctors had yet to overhaul the psychiatric healthcare system completely. Still, during the First World War and in the two decades that followed it, the seeds were planted for important, longlasting, and—in many cases—positive transformations in French psychiatric ideology and practice. Through the interwar period, psychiatry defined itself as a specialty rededicated to medical science. Toulouse and his colleagues attempted to arm psychiatrists with the latest advances in medicine in order to provide active, effective treatments for the mentally ill. Although the efficacy of those treatments has not been evaluated here, the move toward active treatment certainly signaled an important change from policies of neglect. The asylum was not yet abolished by 1939, but mental hygienists and psychiatric reformers did begin the process of tearing down that century-old model of custodial care. Reformers also laid the foundation for new treatment options, including public open psychiatric services, which offered an important alternative to the asylum for middle- and working-class individuals. Along with the advent of private psychoanalysis, the introduction of open services signaled a permanent change in the orientation of psychiatric practice. No longer would psychiatry be limited to the benevolent care of chronic cases. It would thereafter also treat arguably normal individuals who suffered from milder troubles. Beyond what this history says about French medicine and French citizens during a specific era, it also offers an opportunity to draw some general conclusions about how individuals experience and cope with psychological

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trauma. From the French case, we can confirm that the psychological effects of traumatic events can endure well past the conclusion of those events. For French men and women, the effects of the war lasted for years after the cessation of hostilities. Social, political, and economic stresses exacerbated anxiety and depression and delayed the psychological recovery of many individuals. It should be somewhat reassuring to learn from the French case that even major social upheavals, such as a war that eliminated a generation of men, leave relatively few individuals with severe, chronic mental illnesses. Despite the prevalence of psychological trauma in France, there was no vast increase in the incidence of severe mental illnesses. French interwar doctors were probably correct in concluding that the majority of individuals who developed severe disorders were in some way predisposed to them. Many of those individuals might have developed disorders even in the absence of war. The French case also teaches us that psychological trauma has the power not only to affect individual lives but also to change the manner of institutional care. In France, mental hygienists had for years argued for the creation of open psychiatric services. But it was the administrative, economic, and demographic challenges engendered by the war and the perceived influx of psychiatric casualties caused by the war that forced administrators finally to approve those services in Paris. By underscoring (and perhaps exaggerating) the prevalence of psychological trauma among French citizens, Édouard Toulouse and others were able to convince hygienically minded government ministers to make small but symbolic changes in France’s national psychiatric system. Finally, this history should serve as a reminder that the prevalence of illness is often directly related to both the perceived benefits of being ill and the availability of treatment options. In Britain, the prevalence of shell shock appeared to rise after the war, as soldiers returned home and applied for war-neurosis pensions. In France, where no financial benefits were accorded to hysterics and a greater social stigma was attached to the label, there was no apparent rise in the prevalence of war-induced disturbances. Did France have a smaller percentage of “shell-shocked” ex-servicemen? It is unlikely. More likely, many traumatized French veterans either suffered in silence or were diagnosed with other illnesses. Similar conclusions about the relationships between the prevalence of illness and the benefits of being sick can be drawn for civilians. The absence of a substantial rise in asylum admissions after the war should not force us to con-

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clude that few civilians were traumatized. Few individuals saw the decrepit, prison-like asylums, full of their chronic inmates, as enticing or appropriate venues for treatment. When open psychiatric services were created in Paris in 1922, middle- and working-class individuals finally had a place where they could address their relatively “sane” feelings of stress and loss without incurring the mark of institutionalization or the cost of private care. Although the stigma of psychiatric care may have been more difficult to avoid than psychiatric reformers had initially hoped, open services nevertheless attracted a large number of clients. The popularity of open services—demonstrated by the rising numbers of consultations and hospitalizations that those services conducted through the interwar period—suggests that there indeed existed a large pool of patients who required medical assistance to overcome sadness, anxiety, and a range of other problems in the wake of the Great War.

Notes Introduction 1. This incident, which was reported in the Paris newspapers (including Le Temps, Le Figaro, L’Écho de Paris, and L’Humanité) and other international papers (including the New York Times) beginning on May 24, 1920, has been retold by several biographers and historians, including Jean Mélia, Paul Deschanel (Paris: Plon, 1924); Louis Sonolet, La Vie et l’œuvre de Paul Deschanel, 1855–1922 (Paris: Hachette, 1926); William Wiser, The Crazy Years: Paris in the Twenties (New York: Atheneum, 1983); Pierre Rentchnick, Ces Malades qui font l’histoire (Paris: Plon, 1983); and Thierry Billard, Paul Deschanel (Paris: Pierre Belfond, 1991). Several newspapers stuck to the official account of the incident, while others, including Le Temps, supplemented that account with interviews of key individuals. Historians later added additional—often unattributed— information. In retelling the story again here, secondary accounts have been combined with information from Paris newspapers. Particular citations are provided when they are unique to one or more particular accounts. 2. These statements have appeared in several primary and secondary sources, in subtly different versions. See, for example, “Le Président de la République victime d’un accident,” Le Figaro, May 24, 1920, pages 1–2; “L’Accident du Président de la République,” Le Temps, May 26, 1920, pages 1–2; Jean Clair-Guyot, “Le Voyage extraordinaire du Président Deschanel,” Miroir de l’histoire 38 (1953): 234; and André Castelot, “Quand un président de la République perd la tête...” Le Figaro, October 28, 1980, page 32. 3. “L’Accident du Président de la République,” Le Temps, May 26, 1920, pages 1–2; and Castelot, 32. 4. Wiser, 9–10. In another account, Dariot’s wife later remarked, “I saw clearly that he was a gentleman….His feet were so clean.” Clair-Guyot, 234. 5. Beginning the next morning, Deschanel was treated by several other doctors, one of whom gave him an anti-tetanus shot. 6. Marcel Rutin, “Un Accident interrompt le voyage présidentiel,” L’Écho de Paris, May 25, 1920, page 1; Rentchnick, 206; Edwin L. James, “Deschanel Escape Thrills France,” New York Times, May 25, 1920, page 1. 7. “Le Président de la République victime d’un accident,” Le Figaro, May 24, 1920, pages 1–2.

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8. Though the president continued to maintain that he never lost consciousness, he had reported to the sub-prefect, Lesueur, a “hole” in his memory from the time that he fell to the time that he arrived at the gatekeeper’s house. “L’Accident du Président de la République,” Le Temps, May 26, 1920, pages 1–2. 9. “Le Président de la République victime d’un accident,” Le Figaro, May 24, 1920, pages 1–2. 10. “Après l’accident de Montargis,” Le Figaro, May 25, 1920, page 1. 11. The reporter of Le Figaro made note of the window’s poor design in “Le Président de la République victime d’un accident,” Le Figaro, May 24, 1920, pages 1–2. 12. This medical bulletin, from May 28, 1920, is reprinted in Rentchnick, 216. Apparently Rentchnick acquired this and other medical certificates from Deschanel’s family. 13. “Il n’a pas oublié son pyjama / C’est épatant mais c’est comme ça” [He didn’t forget his pajamas / Astonishing, but that’s how it is]. See Wiser, 11, and Castelot, 32. 14. “La Santé de M. Deschanel,” Le Temps, May 31, 1920, page 2; “À l’Élysée,” Le Temps, June 1, 1920, page 2; “La santé de M. Deschanel,” Le Temps, June 2, 1920, page 2; “Deschanel to Rest in Normandy,” New York Times, June 1, 1920, page 2; “Deschanel Off to Rest in Normandy,” New York Times, June 4, 1920, page 17. 15. “French President Returns to Paris,” New York Times, July 1, 1920, page 17. 16. “Frenchmen Want a Vice President,” New York Times, July 12, 1920, page 15; “La Santé de M. Paul Deschanel,” Le Temps, July 13, 1920, page 4; “La Santé de M. Paul Deschanel,” Le Figaro, July 13, 1920, page 1. 17. “Deschanel Has a Relapse,” New York Times, July 13, 1920, page 10; “Differ about Deschanel,” New York Times, July 15, 1920, page 15. 18. “Differ about Deschanel,” New York Times, July 15, 1920, page 15. 19. “La Santé de M. Deschanel,” Le Temps, July 14, 1920, page 4. 20. “Deschanel Is Improving,” New York Times, July 17, 1920, page 6. 21. Rentchnick, 209; Walter Duranty, “Deschanel Resigns, Election Called,” New York Times, September 17, 1920, page 17; and “La Santé de M. Paul Deschanel,” Le Temps, September 17, 1920, page 2. The quotation of the president comes from “France May Choose President September 23,” New York Times, September 18, 1920, page 15. 22. Clair-Guyot, 224. 23. Ibid., and “Le premier voyage du Président de la République: L’Accueil de Bordeaux,” Le Figaro, March 2, 1920, page 1. 24. Clair-Guyot, 225. 25. Ibid., 226. 26. Rentchnick, 209. 27. Auguste Avril, “La Présidence de la République va être vacante,” Le Figaro, September 15, 1920, page 1; Marcel Rutin, “M. Paul Deschanel veut démissionner,” L’Écho de Paris, September 15, 1920, page 1. 28. This medical bulletin, from September 18, 1920, is reprinted in Rentchnick, 217. 29. “La Démission de M. Paul Deschanel,” Le Figaro, September 22, 1920, page 1. 30. “Deschanel’s Fall Due to Cerebral Lesion,” New York Times, May 30, 1920, page 5; “Deschanel Signs Pledge to Resign,” New York Times, September 16, 1920, page 17.

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31. Walter Duranty, “Deschanel Resigns, Election Called,” New York Times, September 17, 1920, page 17. 32. “Deschanel Signs Pledge to Resign,” New York Times, September 16, 1920, page 17. 33. Walter Duranty, “Deschanel Retires to a Sanatorium,” New York Times, September 26, 1920, page 9. 34. “La Santé de M. Paul Deschanel,” Le Temps, September 26, 1920, page 3; “Hopes for Deschanel,” New York Times, September 27, 1920, page 17. 35. Duranty, “Deschanel Retires to a Sanatorium,” New York Times, September 26, 1920, page 9. 36. Ibid. 37. For more on neurasthenia, see Maxime Laignel-Lavastine, The Concentric Method in the Diagnosis of Psychoneurotics (1928; London: Kegan Paul, Trench, Trubner & Co., 1931), 12; Barbara Sicherman, “The Uses of a Diagnosis: Doctors, Patients, and Neurasthenia,” Journal of the History of Medicine and the Allied Sciences 32 (1977): 33–54; Pierre Pichot, “La Neurasthénie, hier et aujourd’hui,” L’Encéphale 20 (1994): 546; Tom Lutz, “Neurasthenia and Fatigue Syndromes,” in A History of Clinical Psychiatry: The Origin and History of Psychiatric Disorders, ed. German E. Berrios and Roy Porter (London: Athlone Press, 1995); and Marijke Gijswijt-Hofstra and Roy Porter, eds., Cultures of Neurasthenia from Beard to the First World War (New York: Rodopi, 2001). 38. Elaine Showalter writes, “Neurasthenia was seen as an acceptable and even impressive illness for men, ideally suited to a capitalist society and to the identification of masculinity with money and property.” See The Female Malady: Women, Madness, and English Culture, 1830–1980 (New York: Penguin Books, 1985), 135. See also Pichot, “La neurasthénie, hier et aujourd’hui,” cited in the previous note. 39. Showalter, The Female Malady, 138; E. E. Southard, Shell-Shock and Other Neuropsychiatric Problems (Boston: W. M. Leonard, 1919), xi–xvii. 40. The sanatorium was later renamed the Clinique Médicale du Château de Reuil. Its name change probably reflected the trend toward medicalizing psychiatric care that was fostered by psychiatric reformers. For a description of the institution’s offerings, see the Index des établissements médicaux, published by La Presse médicale (Paris: Masson, 1939). 41. See Constans, Lunier, and Dumesnil, Rapport général à M. le Ministre de l’Intérieur sur le service des aliénés en 1874 (Paris: Imprimerie National, 1878), cited in Robert Castel, The Regulation of Madness: The Origins of Incarceration in France, trans. W. D. Halls (Berkeley: University of California Press, 1988), 214–15. Castel suggests that at the same time there were some two hundred private establishments that did not specialize in mental illnesses but probably nevertheless accepted some paying patients. In 1908, there were twenty-nine maisons de santé in France. See Emmanuel Régis, Précis de psychiatrie, 4th ed. (Paris: Octave Doin et Fils, 1909), 987–88. In 1939, there were twenty-two private facilities in France that treated patients who had some form of nervous or mental illness. See Index des établissements médicaux (1939). See also the indexes of 1929 and 1934, also published by La Presse médicale. For the development of private institutions, see Dora B. Weiner, The Citizen-Patient in Revolutionary and Imperial Paris (Baltimore: Johns Hopkins University Press, 1993), 252, and Erwin H. Ackerknecht, “Political Prisoners in French Mental Institutions,” Medical History 19 (1975): 251.

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42. For interesting descriptions of nineteenth-century Paris maisons de santé and their famous clients, see Laure Murat, La Maison du docteur Blanche: Histoire d’un asile et de ses pensionnaires de Nerval à Maupassant (Paris: J. C. Lattès, 2001); Jacques Le Breton, La Maison de santé du Docteur Blanche: Ses médecins—Ses malades, thesis for the Paris Faculty of Medicine (Paris: Librairie Médicale Marcel Vigné, 1937); and M. Rivet (née Brierre de Boismont), Les Aliénés dans la famille et dans la maison de santé (Paris: Masson, 1875). Descriptions of twentieth­century clinics can be found in the Index des établissements médicaux, published by La Presse médicale during the interwar period, as well as in advertisements for those clinics found in a range of medical journals. 43. Index des établissements médicaux (1939), 3. 44. Ibid., 9. 45. André Vervoort, “Une Visite à la Malmaison: La Guérison de M. Paul Deschanel et son retour à la vie politique,” L’Éclair, November 25, 1920, page 1. A condensed version of this meeting was reported in the New York Times: “Deschanel Nearly Well,” New York Times, November 26, 1920, page 12. 46. Vervoort, “Une Visite à la Malmaison,” 1. 47. Wiser, 12. 48. See, for example, Martin Stone, “Shellshock and the psychologists,” in The Anatomy of Madness: Essays in the History of Psychiatry, vol. 2., ed. W. F. Bynum, Roy Porter, and Michael Shepherd (New York: Tavistock, 1985); Marc Oliver Roudebush, “A Battle of Nerves: Hysteria and Its Treatment in France during World War I,” Ph.D. dissertation, University of California, Berkeley, 1995; José Brunner, “Psychiatry, Psychoanalysis, and Politics during the First World War,” Journal of the History of the Behavioral Sciences 27 (October 1991): 352–65; Anthony Babington, Shell-Shock: A History of the Changing Attitudes towards War Neurosis (London: Leo Cooper, 1997); Hans Binneveld, From Shellshock to Combat Stress: A Comprehensive History of Military Psychiatry, trans. John O’Kane (Amsterdam: Amsterdam University Press, 1997); Peter Leese, Shell Shock: Traumatic Neurosis and the British Soldiers of the First World War (New York: Palgrave Macmillan, 2002); and Edgar Jones and Simon Wessely, Shell Shock to PTSD: Military Psychiatry from 1900 to the Gulf War (New York: Psychology Press, 2005). 49. See, for example, Showalter, The Female Malady; Showalter, Hystories: Hysterical Epidemics and Modern Media (New York: Columbia University Press, 1997); Mark S. Micale and Paul Lerner, eds., Traumatic Pasts: History, Psychiatry, and Trauma in the Modern Age, 1870–1930 (New York: Cambridge University Press, 2001); Michael Trimble, Post-Traumatic Neurosis: From Railway Spine to the Whiplash (Chichester, N.Y.: Wiley, 1981); Edward Shorter, From Paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era (New York: Free Press, 1992); Ruth Leys, Trauma: A Genealogy (Chicago: University of Chicago Press, 2000); Martha Noel Evans, Fits and Starts: A Genealogy of Hysteria in Modern France (Ithaca: Cornell University Press, 1991); and Étienne Trillat, Histoire de l’hystérie (Paris: Éditions Seghers, 1986). 50. See, for example, German E. Berrios and Roy Porter, eds., A History of Clinical Psychiatry: The Origin and History of Psychiatric Disorders (New York: New York University Press, 1995); Elizabeth Lunbeck, The Psychiatric Persuasion (Princeton, N.J.: Princeton University Press, 1994); David Kennedy Henderson, The Evolution of Psychiatry in Scotland (Edinburgh: E. & S. Livingstone, 1964); Jean Demay, “The Past and the Future of French Psychiatry,” trans. Michel Vale, International Journal of Mental Health 16 (1987): 69–77; Jacques Postel and Claude Qué-

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tel, eds., Nouvelle histoire de la psychiatrie (Paris: Dunod, 1994); and Pierre Pichot, Un Siècle de psychiatrie (Le Plessis-Robinson: Synthélabo, 1996). 51. See, for example, Binneveld, From Shellshock to Combat Stress, and Joanna Bourke, Dismembering the Male: Men’s Bodies, Britain and the Great War (Chicago: University of Chicago Press, 1996). 52. See, for example, Roudebush, “A Battle of Nerves” (dissertation, cited earlier) and “A Battle of Nerves: Hysteria and Its Treatments in France During World War One,” in Traumatic Pasts, ed. Micale and Lerner. 53. Paul Lerner, Hysterical Men: War, Psychiatry, and the Politics of Trauma in Germany, 1890–1930 (Ithaca: Cornell University Press, 2003). 54. Studies that compare conceptions of shell shock in different countries also have been lacking until only recently. See the collection of works published in the Journal of Contemporary History 35:1 (2000), as well as Traumatic Pasts, ed. Micale and Lerner. 55. For other examples of how that goal can be achieved, see Ben Shephard, A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century (Cambridge, Mass.: Harvard University Press, 2001), and Peter Barham, Forgotten Lunatics of the Great War (New Haven: Yale University Press, 2004). 56. See, for example, Jean-Jacques Becker, The Great War and the French People, trans. Arnold Pomerans (Dover, N.H.: Berg, 1985); Stéphane Audoin-Rouzeau and Annette Becker, 14–18: Understanding the Great War, trans. Catherine Temerson (New York: Hill and Wang, 2002); Leonard V. Smith, Stéphane Audoin-Rouzeau, and Annette Becker, France and the Great War, 1914–1918 (Cambridge: Cambridge University Press, 2003); Margaret H. Darrow, French Women and the First World War: War Stories of the Home Front (New York: Berg, 2000); and Patrick Fridenson, ed., The French Home Front, 1914–1918 (Providence, R.I.: Berg, 1992). 57. Ted Bogacz, “War Neurosis and Cultural Change in England, 1914–22: The Work of the War Office Committee on Enquiry into ‘Shell-Shock,’” Journal of Contemporary History 24 (1989): 227–56; Catherine Merridale, “The Collective Mind: Trauma and Shell-Shock in Twentieth-­century Russia,” Journal of Contemporary History 35:1 (2000): 39–55; Annette Becker, “The Avant-garde, Madness, and the Great War,” Journal of Contemporary History 35:1 (2000): 71–84; Caroline Cox, “Invisible Wounds: The American Legion, Shell-Shocked Veterans, and American Society,” in Traumatic Pasts, ed. Micale and Lerner. 58. Ben Shephard, A War of Nerves, cited earlier. 59. Jean-Yves Le Naour, The Living Unknown Soldier: A Story of Grief and the Great War, trans. Penny Allen (2002; New York: Metropolitan Books, 2004). 60. See, for example, Roberts, Civilization without Sexes, cited earlier; Carolyn J. Dean, The Frail Social Body: Pornography, Homosexuality, and Other Fantasies in Interwar France (Berkeley: University of California Press, 2000); Eugen Weber, The Hollow Years (New York: W. W. Norton, 1994); Margaret Randolph Higonnet, Jane Jenson, Sonya Michel, and Margaret Collins Weitz, eds., Behind the Lines: Gender and the Two World Wars (New Haven: Yale University Press, 1987); Wiser, The Crazy Years, and Wiser, The Twilight Years: Paris in the 1930s (New York: Carroll & Graf, 2000); Oliver Bernier, Fireworks at Dusk: Paris in the Thirties (Boston: Little, Brown, 1993); and Anthony Adamthwaite, Grandeur and Misery: France’s Bid for Power in Europe, 1914–1940 (New York: St. Martin’s Press, 1995). 61. See Antoine Prost, Les Anciens combattants et la société française, 1914–1939, 3 vols. (Paris: Presses de la Fondation Nationale des Sciences Politiques, 1977). Later abridged and translated

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Notes to Pages 16–18

as In the Wake of War: “Les Anciens Combattants” and French Society, 1914–1939, trans. Helen McPhail (Providence, R.I.: Berg, 1992). See also Deborah Cohen, The War Come Home: Disabled Veterans in Britain and Germany, 1914–1939 (Berkeley: University of California Press, 2001); Robert Weldon Whalen, Bitter Wounds: German Victims of the Great War, 1914–1939 (Ithaca: Cornell University Press, 1984); and Peter Reese, Homecoming Heroes: An Account of the Reassimilation of British Military Personnel into Civilian Life (London: Leo Cooper, 1992). 62. Daniel J. Sherman has published an exceptional work on this topic. See idem, The Construction of Memory in Interwar France (Chicago: University of Chicago Press, 1999). Prost addresses the memory of war both in his three-volume work and in a subsequent article published in Pierre Nora’s Les Lieux de mémoire. See Antoine Prost, “Les Monuments aux morts,” in Les Lieux de mémoire, vol. 1, ed. Pierre Nora (Paris: Gaillimard, 1984) and “Verdun,” in Realms of Memory: Rethinking the French Past, vol. 3, under the direction of Pierre Nora, ed. Lawrence D. Kritzman, trans. Arthur Goldhammer (New York: Columbia University Press, 1998). See also Omer Bartov, “Martyrs’ Vengeance: Memory, Trauma, and Fear of War in France, 1918–1940,” in The French Defeat of 1940: Reassessments, ed. Joel Blatt (Providence, R.I.: Berghahn Books, 1998). 63. Michel Foucault, Madness and Civilization: A History of Insanity in the Age of Reason, trans. Richard Howard (1965; New York: Vintage Books, 1988) and idem, History of Madness, ed. Jean Khalfa, trans. Jonathan Murphy and Jean Khalfa (New York: Routledge, 2006). The historiography of French psychiatry is extensive. For a small sampling of writers responding to Foucault’s work, see Klaus Dörner, Madmen and the Bourgeoisie: A Social History of Insanity and Psychiatry, trans. Joachim Neugroschel and Jean Steinberg (Oxford: Basil Blackwell, 1981); Robert Castel, L’Ordre psychiatrique: L’Âge d’or de l’aliénisme (Paris: Minuit, 1976) [later translated as The Regulation of Madness]; Marcel Gauchet and Gladys Swain, La Pratique de l’esprit humain: L’Institution asilaire et la révolution démocratique (Paris: Gallimard, 1980); Jan Goldstein, Console and Classify: The French Psychiatric Profession in the Nineteenth Century (New York: Cambridge University Press, 1987); and Robert A. Nye, Crime, Madness, and Politics in Modern France: The Medical Concept of National Decline (Princeton: Princeton University Press, 1984). 64. See, for example, Elisabeth Roudinesco, La Bataille de cent ans: Histoire de la psychanalyse en France, vol. 1, 1885–1939 (Paris: Éditions du Seuil, 1986); Jean-Pierre Mordier, Les Débuts de la psychanalyse en France, 1895–1926 (Paris: François Maspero, 1981); Victor N. Smirnoff, “De Vienne à Paris: Sur les origines d’une psychanalyse ‘à la française,’” Nouvelle Revue de Psychanalyse 20 (1979): 13–58; Jacquy Chemouni, Histoire de la psychanalyse en France (Paris: Presses Universitaires de France, 1991); Marion Michel Oliner, Cultivating Freud’s Garden in France (Northvale, N.J.: Jason Aronson, 1988); Annick Ohayon, L’Impossible rencontre: Psychologie et psychanalyse en France, 1919–1969 (Paris: Éditions la Découverte, 1999). 65. See, for example, Trillat, Histoire de l’hystérie; Pichot, Un Siècle de psychiatrie; and Postel and Quétel, eds., Nouvelle histoire de la psychiatrie. 66. See, for example, Jean-Bernard Wojciechowski, Hygiène mentale et hygiène sociale: Contribution à l’histoire de l’hygiénisme, 2 vols. (Paris: Éditions L’Harmattan, 1997), Anne-Laure Simonnot, Hygiénisme et eugénisme au XXe siècle à travers la psychiatrie française (Paris: Éditions Seli Arslan, 1999), and Michel Huteau, Psychologie, psychiatrie, et société sous la troisième république: La Biocratie d’Édouard Toulouse (1865–1947) (Paris: L’Harmattan, 2002). 67. Ian R. Dowbiggin, Inheriting Madness: Professionalization and Psychiatric Knowledge in Nineteenth-Century France (Berkeley: University of California Press, 1991).

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68. See, for example, Micale and Lerner, Traumatic Pasts; Ruth Leys, Trauma: A Genealogy; Trimble, Post-Traumatic Neurosis; and Lerner, Hysterical Men, all cited earlier.

Chapter One 1. Joseph Jules Dejerine, “Sur l’abolition du réflexe cutané plantaire dans certains cas de paralysies fonctionnelles accompagnées d’anesthésie (hystéro-traumatisme),” February 4, 1915, meeting of the Neurology Society of Paris, Revue neurologique 28 (1914–1915): 521–27. 2. Administration générale de l’Assistance publique à Paris, Compte moral et administratif, présenté au conseil de surveillance de cette administration, 1915 (Paris: Imprimerie Polyglotte Hugonis, 1916), 23. 3. For Dejerine’s view of hysteria, see Joseph Jules Dejerine and E. Gauckler, The Psychoneuroses and Their Treatment by Psychotherapy, trans. Smith Ely Jelliffe (Philadelphia: J. B. Lippincott, 1913); Joseph Jules Dejerine, Sémiologie des affections du système nerveux (Paris: Masson, 1914); Étienne Trillat, Histoire de l’hystérie (Paris: Éditions Seghers, 1986); and Marc Oliver Roudebush, “A Battle of Nerves: Hysteria and Its Treatment in France during World War I,” Ph.D. dissertation, University of California, Berkeley, 1995. 4. Dejerine and Gauckler, viii. 5. Dejerine, “Sur l’abolition du réflexe cutané plantaire,” 523. 6. Ibid., 522. 7. Ibid., 523. 8. Ibid., 527. 9. Henri Baruk, Patients Are People Like Us: The Experiences of Half a Century in Neuropsychiatry, assistance by Jean Laborde, trans. Eileen Finletter and Jean Ayer (1976 New York: William Morrow, 1978), 27–34; John M. S. Pearce, Fragments of Neurological History (London: Imperial College Press, 2003), 352. 10. Victor Parant, père, “Chronique: Le retour à la médecine mentale française,” Annales médico-psychologiques 72 (1915): 402. 11. Ibid., 407–08. See also Ian Dowbiggin, “Back to the Future: Valentin Magnan, French Psychiatry, and the Classification of Mental Diseases, 1885–1925,” Social History of Medicine 9:3 (1996): 383–408. 12. Parant, “Chronique: Le retour à la médecine mentale française,” 402. 13. Ibid., 408. 14. On Kraepelin’s reception in France, see G. E. Berrios and R. Hauser, “Kraepelin,” and P. Hoff, “Kraepelin,” both in A History of Clinical Psychiatry: The Origin and History of Psychiatric Disorders, ed. German E. Berrios and Roy Porter (New York: New York University Press, 1995); Pierre Pichot, “The French Approach to Psychiatric Classification,” British Journal of Psychiatry 144 (1984): 113–18; Pierre Pichot, “Die Geschichte der deutschen Psychiatrie aus der Sicht der französischen Psychiater,” Fortschritte der Neurologie-Psychiatrie 9 (1992): 317–28. For primary sources, see E. Aubry, “Psychoses de l’enfance: A forme de démence précoce (dementia praecocissima)” L’Encéphale 5:2 (1910): 272–78; Henri Claude, “Nécrologie: Emile Kraepelin,” L’Encéphale 22 (1927): 77–78; Evariste Marandon de Montyel, “Les formes de la démence précoce,” Annales médico-psychologiques 2 (1905): 246–60. 15. Antony Rodiet and R. Masselon, “Quelques considérations sur l’étiologie de la mélancolie et sur la place de cette affection dans le cadre nosographique,” L’Encéphale 6:2 (1911): 534.

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16. Gustave Roussy, “À propos de quelques troubles nerveux psychiques observés à l’occasion de la guerre (Hystérie. Hystéro-traumatisme. Simulation.),” February 18, 1915, meeting of the Neurology Society of Paris, Revue neurologique 28 (1914–1915): 425–30. 17. Albert Devaux and Benjamin Joseph Logre, Les Anxieux: Étude clinique (Paris: Masson et Cie, 1917), 283. 18. Paul Voivenel, “Sur la peur morbide acquise,” Annales médico-psychologiques 10 (1918): 283. 19. Joseph Babinski, “Définition de l’hystérie,” Revue neurologique 9 (1901): 1074–80. 20. Joseph Babinski, “Définition de l’hystérie,” April 9, 1908, meeting of the Neurology Society of Paris, Revue neurologique 17 (1908): 384–85. 21. Martha Noel Evans, Fits and Starts: A Genealogy of Hysteria in Modern France (Ithaca: Cornell University Press, 1991), 54. 22. Auguste Tournay, La Vie de Joseph Babinski (New York: Elsevier, 1967), 106–08. 23. For a discussion of medical specialties in France, see George Weisz, “Regulating Specialties in France during the First Half of the Twentieth Century,” Social History of Medicine 15:3 (2002): 457–80. For the relationship between neurology and psychiatry, see Toby Gelfand, “Neurologist or Psychiatrist? The Public and Private Domains of Jean-Martin Charcot,” Journal of the History of the Behavioral Sciences 46:3 (2000): 215–29. 24. This brief sketch of the history of psychiatry in France is drawn primarily from Jan Goldstein, Console and Classify: The French Psychiatric Profession in the Nineteenth Century (New York: Cambridge University Press, 1987); Jacques Postel and Claude Quétel, eds., Nouvelle histoire de la psychiatrie (Paris: Dunod, 1994); Pierre Pichot, Un Siècle de psychiatrie (Le Plesssis-Robinson: Synthélabo, 1996); and Ian Dowbiggin, Inheriting Madness: Professionalization and Psychiatric Knowledge in Nineteenth-Century France (Berkeley: University of California Press, 1991). 25. Dora B. Weiner, “‘Le geste de Pinel’: The History of a Psychiatric Myth,” in Discovering the History of Psychiatry, ed. Mark S. Micale and Roy Porter (New York: Oxford University Press, 1994). 26. Numerous historians have described and critiqued the traitement morale as well as the somewhat similar moral therapy employed by William Tuke in Britain. See Gerald N. Grob, The Mad among Us: A History of the Care of America’s Mentally Ill (New York: Free Press, 1994); Jacques Postel, “The First Psychiatric Experiences of Philippe Pinel at La Maison de Santé Belhomme,” Canadian Journal of Psychiatry 28:7 (1983): 571–76; Jan Goldstein, Console and Classify; and Michel Foucault, Madness and Civilization, trans. Richard Howard (1965; New York: Vintage Books, 1988), among others. 27. This characterization is not just the anti-psychiatric spin on Pinel’s treatment. See, for example, “An Instance of Violent Mania Cured by Prudent and Vigorous Coercion,” in Philippe Pinel, A Treatise on Insanity, trans. D. D. Davis (1806; New York: Hafner Publishing, 1962), 103–06. 28. Colin Jones, “The Treatment of the Insane in Eighteenth- and Early Nineteenth-Century Montpellier: A Contribution to the Prehistory of the Lunatic Asylum in Provincial France,” Medical History 24 (1980): 386. 29. See Lawrence C. McHenry, Jr., Garrison’s History of Neurology (Springfield, Ill.: Charles C. Thomas, 1969), and Webb Haymaker and Francis Schiller, The Founders of Neurology, 2nd ed. (Springfield, Ill.: Charles C. Thomas, 1970). 30. That metaphor, introduced by Foucault, has been adopted by several historians. See Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception, trans. A. M. Sheridan Smith (New York: Vintage Books, 1973); Erwin H. Ackerknecht, Medicine at the Paris Hospital,

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1794–1848 (Baltimore: Johns Hopkins University Press, 1967); Toby Gelfand, Professionalizing Modern Medicine: Paris Surgeons and Medical Science and Institutions in the Eighteenth Century, (Westport, Conn.: Greenwood Press, 1980) and “Gestation of the Clinic,” Medical History 25 (1981): 169–80; Guenter B. Risse, “Clinical Instruction in Hospitals: The Boerhaavian Tradition in Leyden, Edinburgh, Vienna, and Pavia,” Clio Medica 21 (1987–88): 1–19, and “Before the Clinic Was ‘Born’: Methodological Perspectives in Hospital History,” in Institutions of Confinement, ed. Norbert Finzsch and Robert Jütte (New York: Cambridge University Press, 1996). 31. McHenry, 152; Christopher G. Goetz, Michel Bonduelle, and Toby Gelfand, Charcot: Constructing Neurology (New York: Oxford University Press, 1995), 69. 32. For Charcot’s role in the development of French neurology, see Goetz et al., Charcot: Constructing Neurology, and Walther Riese, A History of Neurology (New York: MD Productions, 1959). Robert B. Aird argues that modern neurology did not develop until the mid-twentieth century, when “the scientific techniques of improved neurological diagnosis, therapy, and research had become established.” See Aird, Foundations of Modern Neurology: A Century of Progress (New York: Raven Press, 1994), xi. 33. Dowbiggin, 14. 34. For a description of those critiques, see Dowbiggin. For a history of the attacks on the law of 1838 and attempts to reform that law, see Maurice Desruelles, “Histoire des projets de révision de la loi du 30 juin 1838,” Annales médico-psychologiques 96:1 (1938): 585–623. 35. See, for example, legislative projects by Gambetta and Magnin (1870), Reinach and Lafont (1890–1894), and Dubief (1896–1906). 36. Annex 9, Journal officiel de la république française: Documents parlementaires: Chambre: Session extraordinaire (1893): 5. 37. Ibid., 6. 38. Charles Coury, L’enseignement de la médecine en France: Des origines à nos jours (Paris: Expansion Scientifique Française, 1968), and Weisz, “Regulating Specialties in France.” 39. David Healy, The Creation of Psychopharmacology (Cambridge, Mass.: Harvard University Press, 2002), 86. 40. See, for example, Adrien-Pierre-Léon Granjux, “L’Aliénation mentale dans l’armée,” Le Bulletin médical 8 (1902): 179–82; J. Simonin, “Les Dégénérés dans l’armée. Origine.— Caractères.—Prophylaxie,” Annales d’hygiène publique et de médecine légale 11 (1909): 32–52; and Paul Chavigny, “La Débilité mentale considérée spécialement au point de vue du service militaire: Son expertise médico-légale,” Annales d’hygiène publique et de médecine légale 12 (1909): 393–443. 41. René Charpentier, “Notes sur l’assistance psychiatrique de guerre,” Annales médico­psychologiques 75 (1919): 181–99. 42. See Granjux, “L’Aliénation mentale dans l’armée,” and James Rayneau, “L’Aliénation mentale dans l’armée,” August 2–8, 1909, Congrès des médecins aliénistes et neurologistes de France et des pays de langue française, Revue neurologique 18 (1909): 1026–32 and 1032–43 respectively. 43. Granjux, “L’Aliénation mentale dans l’armée,” 1026. 44. Charpentier, “Notes sur l’assistance psychiatrique de guerre,” 186; Granjux, “L’Aliénation mentale dans l’armée,” 1014. 45. Charpentier, “Notes sur l’assistance psychiatrique de guerre,” 187. Régis’s center was a naval installation. The first army centers were organized in the Fifth Army, in early 1915, by

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Notes to Pages 33–38

Doctor-Inspector Pauzat at Fismes and Épernay. See Henri Damaye, “Aperçu général sur la psychiatrie d’un service d’armée,” Annales médico-psychologiques 74 (1918): 90–98, and Alfred Abadie, “La Neuro-psychiatrie d’urgence aux armées,” October 16, 1915, medical-surgical meeting of the Fifth Army, La Presse médicale (November 18, 1915): 460–61. 46. Michel Dupont, Dictionnaire historique des médecins: Dans et hors de la médecine (Paris: Larousse: 1999), s. v. “Régis.” 47. This ministerial circular was issued on October 9, 1914. See Henri Claude, “L’Organisation et le fonctionnement des centres neurologiques régionaux,” Paris médical 17 (1915): 61–65. 48. “Vœu à Monsieur le Ministre de la Guerre,” Revue neurologique 28 (1914–1915): 452. 49. Regional centers were established in Nancy, Bourg-en-Bresse, Lyon, Marseille, Montpellier, Toulouse, Vichy, Bourges, Tours, Le Mans, Rennes, Caen, and Évreux. See Michel Bonduelle, François Lhermitte, and Jean-Claude Gautier, “La Revue neurologique, 1893–1993,” Revue neurologique 149 (1993): 99–100. 50. Gustave Roussy, “Troubles nerveux psychiques de guerre,” La Presse médicale 23 (April 29, 1915): 141. 51. Gustave Roussy and Jules Boisseau, “Un Centre de neurologie et de psychiatrie d’armée,” Paris médical 19 (1916): 14. 52. Ibid. 53. Charpentier, “Notes sur l’assistance psychiatrique de guerre,” 187. 54. Maurice Dide, “Travaux des centres neurologiques militaires,” Revue neurologique 31 (1917): 460. 55. Roussy and Boisseau, “Un Centre de neurologie et de psychiatrie d’armée,” 14–20, and “Travaux des centres neurologiques militaires,” Revue neurologique 32 (1917): 331–460. 56. Gustave Roussy and J. Lhermitte, Shell Shock, or the Psychoneuroses of War, trans. Wilfred B. Christopherson (London: University of London Press, 1918), 160–61. 57. See, for example, Damaye, “Aperçu général sur la psychiatrie d’un service d’armée,” 91. 58. Babinski endorsed secrecy when completing disability assessments. See Joseph Babinski and Jules Froment, Hysteria or Pithiatism and Reflex Nervous Disorders in the Neurology of War, trans. J. D. Rolleston, ed. E. Farquhar Buzzard (1917; London: University of London Press, 1918), n. 234–35. 59. To take Babinski literally, one could not diagnosis pithiatism for certain until the patient had been cured by persuasion. The circularity of his definition and the difficulties that the circularity posed for diagnostics were noted by many doctors before, during, and after the war. 60. Babinski and Froment, Hysteria or Pithiatism, 228. 61. See “Travaux des centres neurologiques militaires,” Revue neurologique 28 (1914–1915): 1135–1201 and Revue neurologique 30 (1916): 603–749. 62. For Sollier’s views on hysteria, see Sollier, Genèse et nature de l’hystérie (Paris: Félix Alcan, 1897); Sollier, L’Hystérie et son traitement (Paris: Félix Alcan, 1901); Sollier, “De la localisation cérébrale des troubles hystériques,” Revue neurologique 8 (1900): 102–07; Paul Sollier, M. Chartier, Félix Rose, and Villandre, Traité clinique de neurologie de guerre (Paris: Félix Alcan, 1918); Pierre Janet, Psychological Healing: A Historical and Clinical Study, vol. 2, trans. Eden and Cedar Paul (New York: Macmillan, 1925), 804–09; Marc Roudebush, “A Battle of Nerves: Hys-

Notes to Pages 39–45

201

teria and Its Treatments in France during World War One,” in Traumatic Pasts: History, Psychiatry, and Trauma in the Modern Age, 1870–1930, ed. Mark S. Micale and Paul Lerner (New York: Cambridge University Press, 2001), and Roudebush’s dissertation, 63–74. 63. George Dumas, Troubles mentaux et troubles nerveux de guerre (Paris: Félix Alcan, 1919), 151. 64. Ibid., 152. 65. Ibid. 66. Roussy and Lhermitte, Shell Shock or the Psychoneuroses of War, 159–71. 67. Ibid., 159. 68. Ibid., 171. 69. André Léri, “Sur les pseudo-commotions ou contusions médullaires d’origine fonctionnelle,” February 18, 1915, meeting of the Neurology Society of Paris, Revue neurologique 28 (1914–1915): 433–36. 70. André Gilles, “L’Hystérie et la guerre: Troubles fonctionnels par commotion, leur traitement par le torpillage,” Annales médico-psychologiques 8 (1917): 224. 71. Marc Roudebush, “A Patient Fights Back: Neurology in the Court of Public Opinion in France during the First World War,” Journal of Contemporary History 35:1 (2000): 29–38. 72. Damaye, “Aperçu général sur la psychiatrie d’un service d’armée,” 90–98. 73. Régis is quoted at length in Dumas, Troubles mentaux et troubles nerveux de guerre, 196. 74. Emmanuel Régis and Angelo Hesnard, La Psychoanalyse des névroses et des psychoses (Paris: Félix Alcan, 1914). 75. French doctors probably became aware of Freud’s interpretation of war neuroses only years after the war, through works by other French doctors, reviews of Freud’s work, or brief mentions of war neuroses in other translated works of Freud. 76. Freud’s paper “On the Psychoanalysis of War Neuroses” was presented at the Fifth International Psycho-Analytical Congress, held at the Hungarian Academy of Sciences, on Sep­ tember 28 and 29, 1918. It was not published in French until 1984. For French publication information on Freud, see Sigmund Freud, Œuvres complètes: Psychanalysis (Paris: Presses Universitaires de France, 1996). 77. José Brunner, “Psychiatry, Psychoanalysis, and Politics during the First World War,” Journal of the History of the Behavioral Sciences 27 (October 1991): 353–55. 78. Sigmund Freud, “Memorandum on the Electrical Treatment of War Neuroses,” The Standard Edition of the Complete Psychological Works of Sigmund Freud, volume 17 (1917–1919) (1920; London: The Hogarth Press and the Institute of Psycho-Analysis, 1955), 211–15. 79. Paul Sollier, “Statistique des cas de névrose dus à la guerre,” June 8, 1915, meeting of the Academy of Medicine, Bulletin de l’Académie de Médecine 93 (1915): 682–83. 80. Ibid., 684. 81. Sollier et al., Traité clinique de neurologie de guerre, 523. 82. Maxime Laignel-Lavastine, “Travaux des centres neurologiques militaires: Centre neurologique de la IXe région (Tours),” Revue neurologique 28 (1914–1915): 1165. 83. Henri Claude and René Porak, “Les Troubles de la motilité de nature hystérique chez les blessés de guerre,” L’Encéphale 9 (1914–1919): 215. 84. Pierre Marie, “Travaux des centres neurologiques militaires: Service neurologique militarisé de la Salpêtrière,” Revue neurologique 28 (1914–1915): 1146.

202

Notes to Pages 45–48

85. Gilles, “L’Hystérie et la guerre,” 207. 86. Paul Sollier, “Travaux des centres neurologiques militaires: Centre neurologique de la XIVe région (Lyon),” Revue neurologique 28 (1914–1915): 1175. 87. Paul Sollier, “Travaux des centres neurologiques militaires: Centre neurologie de la 14e région (Lyon),” Revue neurologique 30 (1916): 694–95. 88. Sollier later argued that functional disturbances diminished not only because only certain men were predisposed to them but also because these disturbances were less likely to appear once the initial shocks, surprises, and fatigues of war diminished. New classes of soldiers were less prone to those shocks—and hence less likely to develop disturbances—since they had received better training, had heard about the realities of warfare from experienced soldiers, and had even seen battles on film. See Sollier et al., Traité clinique de neurologie de guerre, 523. 89. Pierre Marie, “Travaux des centre neurologiques militaires: Service neurologique militarisé de la Salpêtrière,” Revue neurologique 32 (1917): 341. 90. Maxime Laignel-Lavastine, “Travaux des centre neurologiques militaires: Centre des psychonévroses du gouvernement militaire de Paris,” Revue neurologique 32 (1917): 359. 91. André Léri, “Travaux des centre neurologiques militaires: Centre neuro-psychiatrie de la IIe armée,” Revue neurologique 32 (1917): 452. 92. Roger Dupouy, “Notes statistiques et cliniques sur les troubles neuro-psychiques dans l’armée en temps de guerre,” Annales médico-psychologiques 6 (1914–1915): 444–51. 93. Damaye, “Aperçu général sur la psychiatrie d’un service d’armée,” 90–98. 94. Montembault explained that cases of hystero-traumatism were directed to neuropsychiatric centers. See Ernest Montembault, Contribution à l’étude des maladies mentales chez les militaires pendant la guerre actuelle, thesis for the Paris Faculty of Medicine (Paris: Jouve & Cie, 1916), 25. 95. Charpentier, “Notes sur l’assistance psychiatrique de guerre,” 191–93. 96. Damaye, “Aperçu général sur la psychiatrie d’un service d’armée,” 90–98. Psychiatrists also had to deal with large numbers of soldiers who were simply mentally unfit for military service. Discharges came quickly, but the discharge process was a constant nuisance for psychiatrists. 97. Montembault, 25. 98. Jean Lépine, “Travaux des centres neurologiques militaires: Centre de psychiatrie de la 14e région (Lyon),” Revue neurologique 30 (1916): 701, and Troubles mentaux de guerre (Paris: Masson et Cie, 1917), 7–8. 99. Marie, “Travaux des centre neurologiques militaires,” 341. 100. Male hysteria was certainly not unknown to neurologists, but the conception of a hysteric as a weak-willed female nevertheless endured. Roudebush discusses the gender connotations of the label of hysteria in his dissertation. See also Mark S. Micale, Hysterical Men: The Hidden History of Male Nervous Illness (Cambridge, Mass.: Harvard University Press, 2008); idem, “Charcot and the Idea of Hysteria in the Male: Gender, Mental Science, and Medical Diagnosis in Late Nineteenth-Century France,” Medical History 34 (1990): 363–411; Jan Goldstein, “The Uses of Male Hysteria: Medical and Literary Discourse in Nineteenth-Century France,” Clio Medica 25 (1994): 210–47; and Elaine Showalter, “Male Hysteria,” in The Female Malady: Women, Madness, and English Culture, 1830–1980 (New York: Penguin Books, 1985). 101. Roudebush makes a similar point in his dissertation, 96–100.

Notes to Pages 48–53

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102. See, for example, Roudebush, “A Battle of Nerves,” in Traumatic Pasts, and Joanna Bourke, Dismembering the Male: Men’s Bodies, Britain and the Great War (Chicago: University of Chicago Press, 1996). 103. Robert A. Nye, Masculinity and Male Codes of Honor in Modern France (New York: Oxford University Press, 1993). 104. Françoise Jacob, “La Guerre de 1914 et les ‘Annales médico-psychologiques,’” Recherches contemporaines 3 (1995–1996): 237. 105. “Académie de Médecine,” Le Figaro, December 9, 1914, page 2. 106. “Académie de Médecine,” Le Figaro, June 9, 1915, page 3. 107. This impression is based on a survey of Le Figaro, Le Temps, and L’Écho de Paris through the war years. 108. Paul Chavigny, “Psychiatrie et médecine légale aux armées,” Paris médical 17 (1915): 186. 109. André Gilles, “Commotionnés et hystériques chez nos ennemis et quelques observations sur la psychologie allemande,” Annales médico-psychologiques 75 (1919): 356–66, 489–500. 110. George Dumas and Henri Aimé, Névroses et psychoses de guerre chez les Austro­Allemandes (Paris: Félix Alcan, 1918). 111. Thomas Salmon, “The Care and Treatment of Mental Diseases and War Neuroses (‘Shell Shock’) in the British Army,” Mental Hygiene 1 (1917): 509–47. 112. Ben Shephard, A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century (Cambridge, Mass.: Harvard University Press, 2001), 144. 113. D. Thom, “War Neurosis: Experiences of 1914–1918,” Journal of Laboratory and Clinical Medicine 28 (1943): 586–602, referenced in Onno van der Hart, Annemieke van Dike, Maarten van Son, and Kathy Steele, “Somatoform Dissociation in Traumatized World War I Combat Soldiers: A Neglected Clinical Heritage,” Journal of Trauma and Dissociation 1(4) (2000): 37. 114. Onno van der Hart et al., “Somatoform Dissociation,” 37. 115. Brunner, 352–65, and Paul Lerner, Hysterical Men: War, Psychiatry, and the Politics of Trauma in Germany, 1890–1930 (Ithaca: Cornell University Press, 2003). 116. Lerner, Hysterical Men, 62. 117. Antony Rodiet and André Fribourg-Blanc, La Folie et la guerre, 1914–1918 (Paris: Félix Alcan, 1930), 34. 118. Ibid. 119. Ibid. 120. For histories of French psychiatric classification, see Postel and Quétel, eds., Nouvelle histoire de la psychiatrie; Pierre Pichot, “The Diagnosis and Classification of Mental Disorders in French-Speaking Countries: Background, Current Views and Comparison with Other Nomenclatures,” Psychological Medicine 12 (1982): 475–92; Pichot, “Nosological Models in Psychiatry,” British Journal of Psychiatry 164 (1994): 232–40; and Pichot, “The French Approach to Psychiatric Classification,” cited earlier. For primary works, see Maurice Desruelles, “Les Classifications des maladies mentales dans l’enseignement contemporain,” Annales médico-psychologiques 92:2 (1934): 41–58; Antonin Joseph Adolphe Rouquier, Précis de séméiologie neuro-psychiatrique à l’usage des étudiants et des praticiens (Paris: Octave Doin, 1927); J. Borel, Précis de diagnostic psychiatrique (Paris: Éditions Delmas, 1939); and Emmanuel Régis, Précis de psychiatrie, 4th ed. (Paris: Octave Doin et Fils, 1909).

204

Notes to Pages 53–57

121. Joseph Grasset, “Les Psychonévroses de guerre,” La Presse médicale (April 1, 1915): 105–08. 122. Gilbert Ballet and Joseph Rogues de Fursac, “Les Psychoses ‘commotionnelles’ (Psychoses par commotion nerveuse ou choc émotif),” Paris médical 19 (1916): 2–7. 123. Emmanuel Régis, “Les Troubles psychiques et neuro-psychiques de la guerre,” La Presse médicale (May 27, 1915): 177–79. 124. Gaston Milian, “L’Hypnose des batailles,” Paris médical 17 (1915): 265–70. 125. See, for example, Régis, “Les Troubles psychiques et neuro-psychiques de la guerre,” 177–79. 126. D. Anglade, “Confusion mental,” in Traité de pathologie mentale, ed. Gilbert Ballet (Paris: Octave Doin, 1903), 356–73, and Régis, Précis de psychiatrie, 307–08. 127. Régis, “Les Troubles psychiques et neuro-psychiques de la guerre,” 177–79. 128. Dumas, Troubles mentaux et troubles nerveux de guerre, 73. 129. The patient was called “Oue . . .” in the case study. Albert Mairet and Henri Piéron, “Les troubles de mémoire d’origine commotionnelle,” Journal de psychologie normale et pathologique 2 (1915): 310–13. 130. Ibid., 311. 131. Dumas, Troubles mentaux et troubles nerveux de guerre, 73–88. 132. In his book Shell Shock in France, 1914–1918 (Cambridge: Cambridge University Press, 1940), Charles S. Myers says that he first used the term in the cases he published in the Lancet. The historian Ben Shephard suggests that Myers introduced a term to the medical community that already had been used among troops. See Shephard, A War of Nerves, 1. 133. Charles S. Myers, “A Contribution to the Study of Shell Shock,” Lancet (February 13, 1915): 320. 134. Charles S. Myers, “Contributions to the Study of Shell Shock,” Lancet (January 8, 1916): 65–69. 135. Myers, Shell Shock in France, 1914–1918, 36. 136. Milian, “L’Hypnose des batailles,” 265–70. 137. Ibid. 138. Ibid., 269. 139. Régis, Précis de psychiatrie, s.v. “traumatisme.” 140. For a brief discussion of the medical understanding of commotion before the war, see Lépine, Troubles mentaux de guerre, 49–50. 141. Albert Mairet, Henri Piéron, and Bertha Bouzansky, “De l’existence d’un ‘syndrome commotionnel,’ dans les traumatismes de guerre,” June 1, 1915, meeting of the Academy of Medicine, Bulletin de l’Académie de Médecine 73 (1915): 654–61; “Des variations du ‘syndrome commotionnel,’ suivant la nature des traumatismes, et de son unité,” June 15, 1915, meeting of the Academy of Medicine, Bulletin de l’Académie de Médecine 73 (1915): 690–700; and “Le ‘Syndrome commotionnel,’ au point de vue du mécanisme pathogénique et de l’évolution,” June 22, 1915, meeting of the Academy of Medicine, Bulletin de l’Académie de Médecine 73 (1915): 710–16. 142. Albert Mairet, “Travaux des centres neurologiques militaires: Centre neuro­psychiatrique de la 16e région (Montpellier),” Revue neurologique 32 (1917): 423. 143. Paul Ravaut, “Étude sur quelques manifestations nerveuses, déterminées par le ‘vent de l’explosif,’” June 22, 1915, meeting of the Academy of Medicine, Bulletin de l’Académie de Médecine 73 (1915): 717–20.

Notes to Pages 57–63

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144. Paul Sollier and M. Chartier, “La Commotion par explosifs et ses conséquences sur le système nerveux,” Paris médical 17 (1915): 406–14. 145. Ballet and Rogues de Fursac, “Les Psychoses ‘commotionnelles,’” 2–7. 146. Ibid., 3. 147. Ernest Dupré, “Émotion et commotion,” Bulletin de l’Académie de Médecine 80 (1918): 124–34. 148. Ballet and Rogues de Fursac, “Les Psychoses ‘commotionnelles,’” 6. 149. Régis, Précis de psychiatrie, s.v. “traumatisme.” 150. For the history of trauma, see Michael Trimble, Post-Traumatic Neurosis: From Railway Spine to the Whiplash (Chichester, N.Y.: Wiley, 1981); Micale and Lerner, eds., Traumatic Pasts; and Allan Young, The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder (Princeton: Princeton University Press, 1995). 151. See Lerner, Hysterical Men, for the story of Oppenheim’s “traumatic neurosis.” 152. See Lerner, Hysterical Men, and Micale, “Jean-Martin Charcot and les névroses traumatiques: From Medicine to Culture in French Trauma Theory of the Late Nineteenth Century,” in Traumatic Pasts, ed. Micale and Lerner. 153. Pierre Janet, The Major Symptoms of Hysteria: Fifteen Lectures Given in the Medical School of Harvard University (New York: Macmillan, 1907), 324. 154. For secondary sources on Janet, see Onno van der Hart, Paul Brown, and Bessel A. van der Kolk, “Pierre Janet’s Treatment of Post-traumatic Stress,” Journal of Traumatic Stress 2:4 (1989): 379–95; Young, The Harmony of Illusions, 32–35; and Louis Crocq, Les Traumatismes psychiques de guerre (Paris: Odile Jacob, 1999), 238–39. 155. Montembault, 75. 156. Ibid. 157. Ibid., 76. 158. Caroline Mangin-Lazarus, “Maurice Dide (1873–1944): A Forgotten Hero of French Psychiatry,” ed. Allan Beveridge, trans. Françoise Gaillard, History of Psychiatry 6 (December 1995): 539–48. 159. Maurice Dide, Les Émotions et la guerre (Paris: Félix Alcan, 1918). 160. Dumas, Troubles mentaux et troubles nerveux de guerre. 161. See Dowbiggin, 3, 118; Robert A. Nye, Crime, Madness, and Politics in Modern France: The Medical Concept of National Decline (Princeton: Princeton University Press, 1984), 121–22; and Postel and Quétel, eds., Nouvelle histoire de la psychiatrie, 234–35. 162. Pichot, “The French Approach to Psychiatric Classification,” 114. 163. Dowbiggin, Inheriting Madness, cited earlier. 164. Régis, “Les Troubles psychiques et neuro-psychiques de la guerre,” 177. 165. Paul Chavigny, “Psychiatrie aux armées,” Paris médical 17 (1915): 415. 166. Gilbert Ballet, “Note sur la relation des tremblements et des états émotionnels,” November 4, 1915, meeting of the Neurology Society of Paris, Revue neurologique 28 (1914–1915): 934–36. 167. Régis, “Les Troubles psychiques et neuro-psychiques de la guerre,” 177–79. 168. See Ernest Dupré, “La Mythomanie,” Le Bulletin médical (1905): 311; “La Constitution émotive,” Bulletin de l’Académie de Médecine 79 (1918): 286–88; Ernest Dupré and Charles-Louis Trepsat, “Les Rapports du refoulement psychique et de l’émotivité dans la genèse de certaines

206

Notes to Pages 63–67

psychonévroses,” L’Encéphale 17 (1922): 31–38, 109–14; and Ernest Dupré “Les Déséquilibrés constitutionnels du système nerveux,” in Pathologie de l’imagination et de l’émotivité (Paris: Payot, 1925). 169. Dupré, “La Mythomanie,” 311. Writers who described the unique character of hysterics include Henri Legrand du Saulle, Jean Pierre Falret, Jean Crocq, Henri Claude, and Henri Ey, among others. 170. Montembault, 44–45. 171. Georges Dumas, “La Psychologie de l’hystérie,” Journal de psychologie normale et pathologique (1923): 895–920. 172. Jean-Michel Bégué, “French Psychiatry in Algeria (1830–1962): From Colonial to Transcultural,” History of Psychiatry vii (1996): 533–48; Richard Keller, “Madness and Colonization: Psychiatry in the British and French Empires, 1800–1962,” Journal of Social History 35 (2001): 295–326. For a longer work on colonial psychiatry, see Keller, Colonial Madness: Psychiatry in French North Africa (Chicago: University of Chicago Press, 2007). 173. For another clear example of that racism among psychiatrists, see Paul Corboun, “Psychologie du tirailleur sénégalais,” Nouvelle iconographie de la Salpêtrière 28:1 (1916–1917): 167–83. 174. Antoine Porot, “Centre neurologique de le 19e région (Alger),” Revue neurologique 29:2 (1916): 728. See also Antoine Porot and Angelo Hesnard, Psychiâtrie de guerre: Étude clinique (Paris: Félix Alcan, 1919), Chapter 3. Several of Porot’s and Hesnard’s observations are repeated in Maxime Laignel-Lavastine and Paul Courbon, Les Accidentés de la Guerre: Leur esprit, leurs réactions, leur traitement (Paris: Librairie J.-B. Baillière et Fils, 1919), 22. For more on Porot and his place in the history of “ethnopsychiatry” see Bégué and Keller (both cited earlier), as well as Chapter 6 of Roudebush’s dissertation. 175. Porot, “Centre neurologique,” 728. 176. Ibid., 729. 177. Showalter, 174–75; Salmon, 509–47. 178. Régis, “Les Troubles psychiques et neuro-psychiques de la guerre,” 177–79. 179. André Léri at the December 15, 1916, meeting of the Neurology Society of Paris, Revue neurologique 29:2 (1916): 764. 180. Rodiet and Fribourg-Blanc, La Folie et la guerre, 1914–1918, 135–37. 181. Several twentieth-century studies have found that among those psychiatric patients who convert their psychological troubles to physical symptoms, patients display symptoms that they (and members of their social group) believe to be representative of illness. For just a sampling, see F. J. Ziegler et al., “Contemporary Conversion Reactions: A Clinical Study,” American Journal of Psychiatry 116 (1960): 901–10; David G. Folks, Charles V. Ford, and William M. Regan, “Conversion Symptoms in a General Hospital,” Psychosomatics 25 (1984): 285–95; and J. Frei, “Contribution à l’étude de l’hystérie: Problèmes de définition et évolution de la symptomatologie,” Archives Suisses de Neurologie, Neurochirurgie et de Psychiatrie 134 (1984): 93–129. 182. See, for example, Ballet and Rogues de Fursac, “Les Psychoses ‘commotionnelles,’” 2–7. 183. Raoul-Louis Benon, “Les Maladies mentales et nerveuses et la guerre,” Revue neurologique 28 (1916): 210–15. 184. Henri Vatar, La Grande Guerre et la folie: De l’influence de la guerre de 1914–1918 sur la genèse et l’orientation des conceptions délirantes, thesis for the Paris Faculty of Medicine (Paris: Librairie Littéraire et Médicale, 1919), 12.

Notes to Pages 67–75

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185. See Antony Rodiet and André Fribourg-Blanc, “Influence de la guerre sur l’aliénation mentale à Paris,” Annales médico-psychologiques 88:1 (1930): 5–24, and idem, La Folie et la guerre, 1914–1918, especially 175–87. 186. Encephalitis lethargica was also called von Economo’s encephalitis, after its discoverer, Baron Constantin von Economo. For more recent scientific interpretations on this disease, see S. McCall, J. M. Henry, A. H. Reid, and J. K. Taubenberger, “Influenza RNA Not Detected in Archival Brain Tissues from Acute Encephalitis Lethargica Cases or in Postencephalitic Parkinson Cases,” Journal of Neuropathology and Experimental Neurology 60 (July 2001): 696–704, and A. H. Reid, S. McCall, J. M. Henry, and J. K. Taubenberger, “Experimenting on the Past: The Enigma of von Economo’s Encephalitis Lethargica,” Journal of Neuropathology and Experimental Neurology 60 (July 2001): 663–70. See also Oliver Sacks, Awakenings (1973; New York: Vintage Books, 1999). 187. For examples of the physical and psychological symptoms of encephalitis noted by French doctors, see Victor Truelle and G. Petit, “Les Troubles mentaux dans l’encéphalite épidémique,” August 1–6, 1922, Congrès des aliénistes et neurologistes de France et des pays de langue française, L’Encéphale 17 (1922): 582–86. 188. Auguste Marie, in Rapport sur le service des aliénés du département de la Seine (Paris: Imprimerie Nouvelle, 1925), 59. 189. Rudolphe Lœwenstein and Georges Parcheminey, “La conception psychoanalytique de l’hystérie,” L’Encéphale 27 (1933): 312–30.

Chapter Two 1. S. Imianitoff, Contribution à l’étude du rôle des émotions dans la genèse des psychoses, thesis for the university doctorate, Paris Faculty of Medicine, 1917, 57–59. 2. Ibid., 58. 3. Ibid., 58–59. 4. Philippe Pinel, Traité médico-philosophique sur l’aliénation mentale, 2nd ed. (Paris: Brosson, 1809), xxx. 5. See, for example, Ludger Jules Joseph Lunier, De l’influence des grandes commotions politiques et sociales sur le développement des maladies mentales; mouvement de l’aliénation mentale en France pendant les années 1869 à 1873 (Paris: F. Savy, 1874); Valentin Magnan, Recherches sur les centres nerveux pathologie et physiologie pathologique (Paris: Masson, 1876); and Adam Cygielstrejch, “Les Conséquences mentales des émotions de la guerre,” Annales médico-­psychologiques 70:1 (1912): 129–48; 257–77. Several other works are mentioned in Maurice Leconte, Conflits sociaux et psychoses (Étude médico-sociale): Travail de la clinique des maladies mentales et de l’encéphale (Paris: Doin, 1938), 6. 6. Lunier, De l’influence des grandes commotions politiques et sociales sur le développement des maladies mentales, cited earlier. This study was published earlier as “Influence des événements de 1870–1871 sur le mouvement de l’aliénation mentale en France,” Annales médico-psychologiques 8 (1872): 161–84; 9 (1873): 241–80; 10 (1873): 2–59; 11 (1874): 350–93. 7. On the use of statistical methods by French doctors, including Pinel, see Terence D. Murphy, “Medical Knowledge and Statistical Methods in Early Nineteenth-Century France,” Medical History 25 (1981): 301–19. 8. Lunier, De l’influence des grandes commotions, 22.

208

Notes to Pages 76–85

9. Adam Cygielstrejch, “Les Conséquences mentales des émotions de la guerre,” Annales médico-psychologiques 70:1 (1912): 129–48, 257–77. See also Claude Barrois, “Deux textes prophétiques d’Adam Cygielstrejch parus dans les Annales Médico-Psychologiques en 1912 sur ‘troubles psychiques de guerre durant la guerre russo-japonaise de 1904–1905,’” Annales médicopsychologiques 151:1 (January 1993): 276–80. 10. Cygielstrejch, 142. Italics in original. 11. Calixte Rougé, “Influence de la guerre actuelle,” Annales médico-psychologiques 73 (1916): 425–61. Rougé went on to publish several other statistical analyses of admissions to his asylum in Limoux. See his “Aliénés militaires admis à l’asile de Limoux en 1916 et 1917,” Annales médicopsychologiques 74 (1918): 35–47; “Résumé statistique des militaires internés à l’asile de Limoux,” Annales médico-psychologiques 75 (1919): 271–80; and “Résumé statistique des militaires internés à l’asile de Limoux,” Annales médico-psychologiques 76 (1920): 329–34. 12. Rougé, “Influence de la guerre actuelle,” 432. 13. Ibid. 14. Ibid., 455. 15. Ibid., 456. 16. Ibid., 457–58. 17. Ibid., 458. 18. Ibid., 455. 19. Imianitoff, 133–34. 20. Madeleine Z. Doty, Behind the Battle Line: Around the World in 1918 (New York: Macmillan, 1918), 166. 21. Ibid., 172. 22. Italics in the original. See Chaslin’s report on the service of mentally ill at the Salpêtrière, in Préfecture du département de la Seine, Direction des affaires départementales, Rapport sur le service des aliénés du département de la Seine (Paris: Imprimerie Nouvelle, 1918), 264. 23. Leonard V. Smith, Stéphane Audoin-Rouzeau, and Annette Becker, France and the Great War, 1914–1918 (Cambridge: Cambridge University Press, 2003), 68–71. 24. The subject of the case is called Madame “Oul . . .” in the thesis. Imianitoff, 92–93. 25. Ibid., 92. 26. Émile Durkheim, Suicide: A Study in Sociology, trans. John A. Spaulding and George Simpson (1897; Glencoe, Ill.: Free Press, 1951). 27. Suzanne Serin, “Une Enquête médico-sociale sur le suicide à Paris,” La Prophylaxie mentale 2 (1926): 230–35. 28. Ibid., 232. 29. Maurice Halbwachs, The Causes of Suicide, trans. Harold Goldblatt (1930; New York: Free Press, 1978). 30. Ibid., 230. 31. Walter A. Lunden, “Suicides in France, 1910–43,” American Journal of Sociology 52:4 (1947): 321–33. 32. Ibid., 322. 33. Ibid., 323. 34. Imianitoff, 93. 35. For discussions of the unique challenges that faced Alsatians, see David Allen Harvey,

Notes to Pages 85–91

209

“Lost Children or Enemy Aliens? Classifying the Population of Alsace after the First World War,” Journal of Contemporary History 34 (1999): 537–54, and Laird Boswell, “Franco-Alsatian Conflict during the Phoney War,” Journal of Modern History 71 (September 1999): 552–84. 36. Paul Courbon, “De l’influence de la guerre sur la délinquance juvénile en Alsace­Lorraine,” L’Encéphale 16 (1921): 136–40, 202–06. 37. These challenges were not unique to Alsatians. In Paris, Marcel Briand reported that admissions to the Sainte-Anne asylum rose during the war because of the difficulty women faced in watching over their children and bringing home the daily bread. Briand recommended establishing a daycare system for working mothers. See Préfecture du département de la Seine, Direction des affaires départementales, Rapport sur le service des aliénés du département de la Seine, 1916 (Paris: Imprimerie Nouvelle, 1917), 51. 38. Paul Courbon, “De l’influence du retour de l’Alsace à la France sur les psychopathes Alsaciens,” Annales médico-psychologiques 76 (1920): 489–500. 39. Henri Beaudouin and Raymond-René Briau, “Sur les méconnaissances systématiques: Négation de décès,” L’Encéphale 29 (1934): 317. 40. Ibid. 41. Ibid. 42. See the Rapport sur le service des aliénés du département de la Seine (1911–1925) and the Annuaire statistique de la ville de Paris (1900–1940). 43. See the Annuaire statistique de la France (1921–1952). 44. Antony Rodiet and André Fribourg-Blanc, “Influence de la guerre sur l’aliénation mentale à Paris,” Annales médico-psychologiques 88:1 (1930): 22. See also Rodiet and Fribourg-Blanc, La Folie et la guerre, 1914–1918 (Paris: Félix Alcan, 1930) for an in-depth discussion of mental illness in soldiers. 45. Rodiet and Fribourg-Blanc, La Folie et la guerre, 3–4. 46. Ibid., 4. 47. Rodiet and Fribourg-Blanc, “Influence de la guerre sur l’aliénation mentale à Paris,” 24. 48. Magnan, Recherches, cited earlier. 49. J.-M. Dupain, in Rapport sur le service des aliénés du département de la Seine, 1915, 86. 50. The statistics in this section were derived from the Rapport sur le service des aliénés du département de la Seine. 51. Wine and alcohol consumption rates for 1830–1939 were reported in the Annuaire statistique de la France (1939), 31–32. 52. Jan Goldstein reports that in 1882 and 1883, 89 of the 500 women admitted to the Salpêtrière (17.8 percent) were diagnosed as hysterical or manifested some hysterical symptoms. Goldstein, Console and Classify: The French Psychiatric Profession in the Nineteenth Century (New York: Cambridge University Press, 1987), 322. It is possible that the incidence of hysteria rose after 1880, but more probably, the apparent disparity between the figures from 1877–1880 and those from 1882–1883 is due to Goldstein’s inclusion of patients with hysterical symptoms who received other diagnoses. Her statistic is based on admissions ledgers, which listed symptomology with the certificate of admission. The figures reported above are taken from reports from asylums to the Prefecture of the Seine and are restricted to patients with the diagnosis of hysteria. 53. See Mark S. Micale, “Charcot and the Idea of Hysteria in the Male: Gender, Mental Sci-

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Notes to Pages 93–102

ence, and Medical Diagnosis in Late Nineteenth-Century France,” Medical History 34 (1990): 372. Micale notes the variety of sources from which Charcot received patients, including the General Infirmary of the Salpêtrière and the outpatient clinic. 54. Registres des entrées—Salpêtrière, Les Archives de l’Assistance Publique à Paris, series 1Q2. 55. Ministère de la Guerre, Statistique médicale de l’armée métropolitaine, 1920–1921 (Paris: Imprimerie Nationale, 1925).

Chapter Three 1. Charles Vallon, “Un Cas d’épilepsie devant le tribunal des pensions,” October 8, 1923, meeting of the Société de médecine légale, Annales de médecine légale 3 (1923): 566–72. 2. Raoul-Louis Benon, “Les Maladies mentales et nerveuses et la pratique des réformes no. 1,” Revue neurologique 30 (1917): 306–09. 3. Vallon wrote that B. appealed for a “gratification,” but B. was more likely appealing for a pension. The term “gratification” was superseded by the pension law of 1919, which was in effect at the time of this appeal. 4. Vallon, 568. 5. Vallon does not indicate the level of pension that was awarded, but it can be assumed that B. received the 60 percent pension that was repeatedly recommended by physicians reviewing his case. 6. The historian Antoine Prost provides clear charts that track the changes in pension allocations from 1914 through 1918 in Les Anciens combattants et la société française, 1914–1939, vol. 2 (Paris: Presses de la Fondation Nationale des Sciences Politiques, 1977), 251 and Annex, table 45. 7. To untangle the web of pension rules, see Antoine Prost, Les Anciens combattants et la société française, 1914–1939, vol. 1; Charles Valentino, Militaires, blessés et infirmes: Réformes, gratifications, et pensions, 1914–1918 (Paris: Berger-Levrault, 1918) and his Accidents du travail et blessures de guerre, thesis for the Faculty of Law, University of Montpellier, 1917. The history of pension laws was also recounted by several legislators during the war as part of their reports on legislative projects. 8. Laws concerning pensions for the army and the navy were enacted on April 11 and 18, 1831. See Le Moniteur universel (April 21, 1831): 855–57. See also Prost, Les Anciens combattants, 1: 14–15, and either work by Valentino for in-depth discussions of those laws. 9. Prost, Les Anciens combattants, 1: 13–14. 10. Ibid., 11. 11. Ibid., 14. 12. Ordinance of August 27, 1814, Le Moniteur universel (September 22, 1814): 1064–66. 13. Valentino, Accidents du travail et blessures de guerre, 19. 14. Ibid., 19; Prost, Les Anciens combattants, 1: 14–15. 15. Le Moniteur universel (July 2, 1861): 1013. The tables are not included in the journal’s pages. 16. Instruction of November 6, 1875. See Valentino, Militaires, blessés et infirmes, 36–40. 17. Law of April 1, 1898, Journal officiel de la république française: Lois et décrets (April 3, 1898): 2045. See also Valentino, Militaires, blessés, et infirmes, 30–31. 18. Law of March 21, 1905, Journal officiel de la république française: Lois et décrets (March 23, 1905): 1869–81. See also Valentino, Militaires, blessés et infirmes, 31.

Notes to Pages 102–108

211

19. Journal officiel de la république française: Lois et décrets (February 15, 1906): 1002. 20. The most complete grouping of references to these laws, decrees, circulars, and instructions can be found in Législation de la Guerre de 1914: Lois, décrets, arrêtés ministériels, et circulaires ministérielles avec références au Recueil Sirey, au Journal du Palais et aux Pandectes françaises, 3 vols. (Paris: Librairie de la Société du Recueil Sirey, 1919), and Valentino, Militaires, blessés et infirmes. 21. Prost, Les Anciens combattants, 1: 15. As of 1914, the categories of temporary discharges were backwards compared to those of definitive discharges: a temporary discharge no. 1 was awarded to soldiers whose infirmity was not imputable to military service. This oddity was corrected (that is, reversed) by the ministerial circular of August 25, 1917. See Valentino, Militaires, blessés et Infirmes, 31–32. 22. Prost, Les Anciens combattants, 1: 8. 23. The table from 1887 is reprinted in several places, including Valentino, Militaires, blessés et infirmes, 180–86. 24. Secrétariat d’état aux anciens combattants, Guide-Barème des invalidités: Applicable au titre du code des pensions militaires d’invalidité et des victimes de la guerre (Paris: Imprimerie Nationale, 1976), 17. 25. Valentino, Militaires, blessés et infirmes, 8–9. 26. Valentino, Accidents du travail et blessures de guerre, 83. 27. Secrétariat d’état aux anciens combattants, Guide-Barème des invalidités, 18. 28. As reprinted in Secrétariat d’état aux anciens combattants, Guide-Barème des invalidités, 107–08. 29. As noted by Grasset, the discharge commission rather than the diagnosing doctor often made the final pronouncement on the level of invalidity. December 15, 1916, meeting of the Neurology Society of Paris, Revue neurologique 30 (1916): 769–70. 30. Ibid., 750–809. 31. These opinions had been rendered previously; see “Vœux émis par la Société de Neurologie de Paris,” October 21, 1915, meeting of the Neurology Society of Paris, Revue neurologique 28 (1914–1915): 1248–49. They were confirmed subsequently; see Joseph Babinski and Jules Froment, Hysteria or Pithiatism and Reflex Nervous Disorders in the Neurology of War, trans. J. D. Rolleston, ed. E. Farquhar Buzzard (1917; London: University of London Press, 1918), 234, and the March 20, 1919, meeting of the Neurology Society of Paris, Revue neurologique 35 (1919): 229. 32. December 15, 1916, meeting of the Neurology Society of Paris, Revue neurologique 30 (1916): 763. 33. Ibid., 764. 34. Ibid. 35. Ibid., 769–70. Italics in the original. 36. Ibid., 790. 37. Ibid., 807. 38. In Les Anciens combattants, Prost traces the history of the veterans’ movement in France from its genesis during World War I through the interwar period. Volume 1 in particular addresses the collective quest of former combatants to ameliorate the process of discharge and to improve pensions. See also the abridged English translation, In the Wake of War: “Les Anciens Combattants” and French Society, 1914–1939, trans. Helen McPhail (Providence, R.I.: Berg, 1992).

212

Notes to Pages 109–112

39. Prost, In the Wake of War, 1. 40. Ibid., 99. 41. Prost traces the efforts of veterans’ pressure groups, especially after the pension law reform was passed, in Les Anciens combattants, 2: 235–53. For more on French pressure groups, see Jean Meynaud, Les groupes de pression en France (Paris: Armand Colin, 1958), and Meynaud, Nouvelles études sur les groupes de pression en France (Paris: Armand Colin, 1962). 42. Prost recounts this episode in Les Anciens combattants, 1: 40–43. 43. Prost, In the Wake of War, 31. 44. See André Gellé, Le Droit à pension: Les invalides de la guerre de 1914–1918, doctoral thesis, University of Paris, Faculty of Law (Paris: Les Presses Universitaires de France, 1923), 25–27, as well as Valentino, Accidents du travail et blessures de guerre. Physicians also made connections between workplace accidents and war-related neuropsychiatric troubles. See Maxime LaignelLavastine and Paul Courbon, Les Accidentés de la guerre: Leur esprit, leurs réactions, leur traitement (Paris: Librairie J.-B. Baillière et Fils, 1919). 45. Report presented July 21, 1916: Annex 2838, Journal officiel de la république française Documents parlementaires: Chambre (1916): 1993. For an in-depth analysis of the legal basis of pension legislation in France and in other countries, see Gellé, Le Droit à pension. 46. Journal officiel de la république française: Débats parlementaires: Chambre (November 23, 1917): 3015. 47. Journal officiel de la république française: Débats parlementaires: Sénat (September 17, 1918): 608. 48. Ibid. 49. See Gellé, Le Droit à pension, 39. 50. Deborah Cohen, The War Come Home: Disabled Veterans in Britain and Germany, 1914–1939 (Berkeley: University of California Press, 2001). While British veterans received little state aid, German veterans became model state welfare cases. Cohen shows that, ironically, British veterans remained loyal to their neglectful state, while the welfare-recipient Germans remained at odds with the Weimar Republic. 51. Annex 536, Journal officiel de la république française: Documents parlementaires: Chambre (1915): 61. 52. Journal officiel de la république française: Débats parlementaires: Sénat (September 17, 1918): 605. 53. Ibid. 54. For a more full discussion of solidarity among politicians and between politicians and soldiers, see Pascal Doriguzzi, La III° République et la solidarité: La Socialisation de l’infirmité, dissertation for the Faculty of Law and Economic Sciences, University of Montpellier, 1989. 55. Journal officiel de la république française: Débats parlementaires: Sénat (February 5, 1918): 307. 56. Ibid., 309. 57. Journal officiel de la république française: Débats parlementaires: Sénat (September 17, 1918): 606. 58. Ibid. 59. Journal officiel de la république française: Lois et décrets (April 2, 1919): 3382–94. See articles 10 and 64.

Notes to Pages 112–115

213

60. See the law of April 9, 1898, Journal officiel de la république française: Lois et décrets (April 10, 1898): 2209–12. 61. Journal officiel de la république française: Lois et décrets (April 2, 1919): 3382. 62. Annex 1410, Journal officiel de la république française: Documents parlementaires: Chambre (1915): 1140–49; Journal officiel de la république française: Lois et décrets (December 11, 1916): 10668. 63. See articles 10 and 64 of the law. 64. The ability to choose one’s own surgeon was added in 1922. Journal officiel de la république française: Lois et décrets (July 23, 1922): 7711. 65. Article 64 of the law of 1919, which pertained to the rights to hospitalization, was revised numerous times over the interwar period, as physicians, veterans, and politicians wrestled for administrative control and disputed appropriate fees for care. For a legal analysis of those changes see Christiane Mirande, Les Soins gratuits aux victimes de la guerre (Article 64 de la loi du 31 Mars 1919) (Paris, Jouve & Cie, 1942). 66. Decree of May 29, 1919, Journal officiel de la république française: Lois et décrets (June 13, 1919): 6095. 67. Ibid., 6100. 68. See Elaine Showalter, The Female Malady: Women, Madness, and English Culture, 1830– 1980 (New York: Penguin Books, 1985), 190; Ben Shephard, A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century (Cambridge, Mass.: Harvard University Press, 2001), 143–60; Eric Leed, No Man’s Land: Combat and Identity in World War I (New York: Cambridge University Press, 1979), 181–89; Ted Bogacz, “War Neurosis and Cultural Change in England, 1914–22: The Work of the War Office Committee on Enquiry into ‘Shell-Shock,’” Journal of Contemporary History 24 (1989): 227–56; Caroline Cox, “Invisible Wounds: The American Legion, Shell-Shocked Veterans, and American Society,” in Traumatic Pasts: History, Psychiatry, and Trauma in the Modern Age, 1870–1930, ed. Mark S. Micale and Paul Lerner (New York: Cambridge University Press, 2001), 298–300; and Joanna Bourke, Dismembering the Male: Men’s Bodies, Britain and the Great War (Chicago: University of Chicago Press, 1996), 109. 69. As mentioned in Chapter 1, more than 150,000 British men applied for pensions for warinduced psychiatric disorders by 1939. See Shephard, A War of Nerves, 144. 70. The financial and administrative burdens proved too great for the Germans, who stopped awarding pensions for shell shock in 1926. See Shephard, A War of Nerves, 152. 71. Journal officiel de la république française: Lois et décrets (April 2, 1919): 3387. This equation of a widow and the wife an aliéné is discussed more fully in the following chapter. 72. See the extended debate in the Société médico-psychologique about the rights to pensions of patients with precocious dementia: Joseph Capgras, “Réformes de déments précoces,” May 27, 1918, meeting of the Société médico-psychologique, Annales médico-psychologiques 74 (1918): 110–22; “Réformes de déments précoces,” June 24, 1918, meeting of the Société médicopsychologique, Annales médico-psychologiques 74 (1918): 197; “Réformes de déments précoces,” July 29, 1918, meeting of the Société médico-psychologique, Annales médico-psychologiques 74 (1918): 291–95. 73. Henri Colin and Eugène Minkowski, “Les Conséquences de la loi de réformes et pensions du 31 mars 1919 dans le domaine des maladies mentales,” Annales médico-psychologiques (1921): 208.

214

Notes to Pages 115–126

74. Ibid., 209. 75. Ibid., 215. 76. Ibid. 77. E. Martimor, “Pensions militaires pour troubles mentaux antérieurs à la guerre,” Annales médico-psychologiques 83:1 (1925): 229–34. 78. Ibid., 230. 79. Ibid., 234. 80. Louis Parant, “Le Principe de la présomption légale d’origine et les conséquences de la loi du 31 mars 1919 sur les pensions militaires,” Annales médico-psychologiques 80:1 (1922): 133–40. 81. Ibid. 82. Pierre Beaussart, “Aliénation mentale et loi du 31 mars 1919 sur les pensions militaires,” Annales médico-psychologiques 79:2 (1921): 311–13. 83. According to Beaussart, patients were ultimately given that right by way of ministerial instructions and circulars. Ibid., 312. 84. Ibid., 314. 85. Ibid., 315. 86. Ibid. 87. Ibid., 316. 88. Colin and Minkowski, 217. 89. Prost, Les Anciens combattants, 1: 78. 90. Journal officiel de la république française: Lois et décrets (January 20, 1920): 1075; Prost, Les Anciens combattants, 1: 78. 91. See the decree of February 22, 1929, in Journal officiel de la république française: Lois et décrets (March 28, 1929): 3647–59. 92. Ibid., 3657. 93. Ibid. 94. That comment was made by Louis Puech. See the Journal officiel de la république française: Débats parlementaires: Chambre (November 27, 1917): 3037–48.

Chapter Four Epigraph: E. B., “La Grande Pitié des fous de guerre,” Journal des mutilés et réformés (August 31, 1930): 1. 1. That figure was referenced by several writers, including F. Laûx [G. Laûx?], “Les Aliénés,” Journal des mutilés et réformés (November 28, 1925): 2, and Jean Penquer, “Les Aliénés,” Journal des mutilés et réformés (December 5, 1925): 2. 2. E. B., “La Grande Pitié des fous de guerre,” 1. 3. Antony Rodiet and André Fribourg-Blanc reported that they analyzed the dossiers of twenty-five thousand soldiers seen for psychiatric disturbances at Val-de-Grâce. Their analyses resulted in two publications, Antony Rodiet and André Fribourg-Blanc, “Influence de la guerre sur l’aliénation mentale à Paris,” Annales médico-psychologiques 88:1 (1930): 5–24, and idem, La Folie et la guerre, 1914–1918 (Paris: Félix Alcan, 1930). 4. Administration générale de l’Assistance publique à Paris, Compte moral et administratif de l’exercice 1914, présenté au conseil de surveillance de cette administration (Montévrain: Imprime-

Notes to Pages 126–128

215

rie Typographique de l’École d’Alembert, 1915), 30. Civilian hospitals had served the needs of pensioned soldiers since at least the nineteenth century. See S. Borsa and C.-R. Michel, Des hôpitaux en France au XIXe siècle (Paris: Hachette, 1985). 5. Administration générale de l’Assistance publique à Paris, Compte moral et administratif de l’exercice 1915, présenté au conseil de surveillance de cette administration (Paris: Imprimerie Polyglotte Hugonis), 23. 6. Joseph Jules Dejerine, “Service neurologique militarisé de la Salpêtrière,” Revue neurologique 28 (1914–1915): 1136–39. 7. Gilbert Ballet and Joseph Rogues de Fursac, “Les Psychoses ‘commotionnelles’ (Psychoses par commotion nerveuse ou choc émotif),” Paris médical 19 (1916): 2–7; Paul Juquelier, “Chronique,” Annales médico-psychologiques 76 (1920): 193–200; Jean-Bernard Wojciechowski, Hygiène mentale et hygiène sociale: Contribution à l’histoire de l’hygiénisme, vol. 2 (Paris: Éditions L’Harmattan, 1997), 21–31. 8. For information on the history of Les Invalides, see Douglas Johnson, “Les Invalides, Paris,” History Today 41 (February 1991): 62–63, and Isser Woloch, “‘A Sacred Debt’: Veterans and the State in Revolutionary and Napoleonic France,” in Disabled Veterans in History, ed. David A. Gerber (Ann Arbor: University of Michigan Press, 2000). 9. A decree issued by the minister of war on January 2, 1918, specified these rules. See the Journal officiel de la république française: Lois et décrets (January 4, 1918): 164, as well as Georges Clemenceau, “Rapport au Président de la République française: ‘L’Institution des Invalides,’” [and response by Poincaré] La Revue philanthropique 39 (1918): 25–27. 10. Justin Godart, then the undersecretary of the health service, set forth the rules of administration in an instruction from January 25, 1918. See Justin Godart, “Instruction pour le fonctionnement de l’institution des Invalides,” La Revue philanthropique 39 (1918): 227–32. See also Louis Mournier, “Décret de réorganisation relatif au fonctionnement de l’institution des Invalides,” La Revue philanthropique 39 (1918): 440–46, and Journal officiel de la république française: Lois et décrets (January 4, 1918): 164. 11. Compte moral et administratif de l’exercice 1920, présenté au conseil de surveillance de cette administration (Paris: Imprimerie Polyglotte Hugonis, 1921), 126. 12. Decree of September 17, 1920, Journal officiel de la république française: Lois et décrets (September 22, 1920): 13926–27. 13. René Poudevigne, “Les Aliénés de guerre,” Journal des mutilés et réformés (November 30, 1930): 2. 14. Rodiet and Fribourg-Blanc, La Folie et la guerre, 1914–1918, 163–73. 15. Caroline Cox, “Invisible Wounds: The American Legion, Shell-Shocked Veterans, and American Society,” in Traumatic Pasts: History, Psychiatry, and Trauma in the Modern Age, 1870– 1930, ed. Mark S. Micale and Paul Lerner (New York: Cambridge University Press, 2001). 16. Cox notes that many veterans were seen at outpatient clinics. The historian Ben Shephard reports that many American veterans with psychiatric disabilities ultimately received specialized treatment at veterans’ hospitals. See Ben Shephard, A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century (Cambridge, Mass.: Harvard University Press, 2001), 153. 17. The institution carried two names because, until 1842, the commune in which it was situated was called “Charenton–Saint-Maurice.” In that year, the commune split in two. The “Maison of Charenton” was officially attached to the commune of Saint-Maurice and contin-

216

Notes to Pages 129–135

ued to be called by both names by doctors and administrators. Histories of Charenton–Saint­Maurice can be found in Henri Baruk, Psychiatrie médicale, physiologique, et expérimentale: Séméiologie—Thérapeutique (Paris: Masson et Cie, 1938), 728–45; Baruk, Patients Are People Like Us: The Experiences of Half a Century in Neuropsychiatry, assistance by Jean Laborde, trans. Eileen Finletter and Jean Ayer (1976; New York: William Morrow, 1978); Julien Raynier and Henri Beaudouin, L’Assistance psychiatrique française, 3rd ed. (Paris: Baillarger, 1949), 22–23; and Adeline Fride, “Charenton: Ou la chronique de la vie d’un asile de la naissance de la psychiatrie à la sectorisation,” doctoral thesis, university unknown, 1983, http://www.serpsy.org/ histoire/memoire_adeline.html (accessed November 29, 2008). 18. André Antheaume, “Chronique,” L’Informateur des aliénistes et des neurologistes 15:6 (1920): 161–65. 19. Ibid., 164. 20. André Antheaume, “Chronique,” L’Informateur des aliénistes et des neurologistes 15:7 (1920): 195–200. 21. Article 112 of the law of July 31, 1920, Journal officiel de la république française: Lois et décrets (August 1, 1920): 10942. 22. See the chronicles presented by André Antheaume in L’Informateur des aliénistes et des neurologistes, as well as articles in the Journal des mutilés et réformés throughout the 1920s, including G. Laûx, “Les Aliénés à St-Maurice,” Journal des mutilés et réformés (May 27, 1922): 1; idem, “Est-ce un pouponnière ou un asile d’aliénés?” Journal des mutilés et réformés (May 12, 1923): 1; and idem, “Les Mutilés du cerveau,” Journal des mutilés et réformés (May 19, 1928): 1. 23. See André Antheaume, “Chronique,” L’Informateur des aliénistes et des neurologistes 16:7 (1921): 151; Laûx, “Les Aliénés,” Journal des mutilés et réformés (November 28, 1925): 2; and idem, “Est-ce un pouponnière ou un asile d’aliénés?”1. 24. Laûx, “Est-ce un pouponnière ou un asile d’aliénés?” 1. 25. See Laûx, “Les Aliénés,” Journal des mutilés et réformés (November 28, 1925): 2, and Penquer, “Les Aliénés,” 2. 26. G. Laûx, “Les Aliénés hospitalisés dans la Seine,” Journal des mutilés et réformés (March 20, 1926): 2. 27. Ibid. 28. Saint-Germain [Laûx?], “Les Aliénés hospitalisés dans le département de la Seine,” Journal des mutilés et réformés (April 17, 1926): 4. 29. Ibid. 30. Ibid. 31. Laûx, “Les Mutilés du cerveau,” 1. 32. Journal officiel de la république française: Lois et décrets (April 2, 1919): 3387. 33. René Poudevigne, “Les Femmes des aliénés de guerre,” Journal des mutilés et réformés (April 4, 1925): 2. 34. René Poudevigne, “Les Blessés du cerveau et l’article 55,” Journal des mutilés et réformés (March 31, 1923): 1. See also René Poudevigne, “Les Pensions des femmes d’internés,” Journal des mutilés et réformés (May 15, 1926): 2, and René Poudevigne, “Pour les femmes d’internés,” Journal des mutilés et réformés (October 30, 1926): 2. 35. Poudevigne purposefully called them “wounded of the brain” [blessé du cerveau] rather than the less dignified “alienated.” 36. Poudevigne, “Les Femmes des aliénés de guerre,” 2.

Notes to Pages 135–140

217

37. Ibid. 38. A third rate, the “normal” rate, was given to wives whose husbands died of illnesses related to their military service, rather than wounds. For officers and under-officers, the normal rate fell between the rate of reversion and the exceptional rate. For soldiers, however, the normal rate and the exceptional rate were equal. 39. Proposition of law made on November 3, 1925, Annex 2009, Journal officiel de la république française: Documents parlementaires: Chambre: Session extraordinaire (1925): 21–22. 40. Ibid. 41. Ibid. 42. Annex 2417, Journal officiel de la république française: Documents parlementaires: Chambre (1926): 51. 43. René Poudevigne, “Pour les femmes des internés,” Journal des mutilés et réformés (March 13, 1926): 1–2. See also the editor’s note following René Poudevigne, “Pour les femmes d’internés,” Journal des mutilés et réformés (October 30, 1926): 2, and the report of June 30, 1926, Annex 3093, Journal officiel de la république française: Documents parlementaires: Chambre (1926): 931. 44. Article 97 of the law of December 19, 1926, Journal officiel de la république française: Lois et décrets (December 19, 1926): 13172. 45. L. Dauphin, “La Pension des femmes d’aliénés,” Journal des mutilés et réformés (March 5, 1927): 2. 46. A. Crucis, “La Grande Détresse des aliénés,” Journal des mutilés et réformés (December 9, 1922): 2. See also Ch. Scelles, “Pour les aliénés,” Journal des mutilés et réformés (February 2, 1924): 1–2. 47. Jean Penquer, “Les Aliénés,” Journal des mutilés et réformés (December 5, 1925): 2. 48. J. Ancelet, “Les Aliénés de la guerre,” Journal des mutilés et réformés (July 7, 1929): 2. 49. Ibid. 50. René Poudevigne, “La Triste Situation des internés de guerre,” Journal des mutilés et réformés (December 31, 1927): 3. 51. G. L. [Laûx?], “Les Aliénés de guerre,” Journal des mutilés et réformés (January 7, 1928): 2, and idem, “Les Aliénés,” Journal des mutilés et réformés (June 16, 1929): 2. 52. G. L., “Les Aliénés de guerre” (January 7, 1928): 2. 53. Laûx, “Les Aliénés” (June 16, 1929): 2. 54. G. L., “Les Aliénés de guerre” (January 7, 1928): 2. 55. Ibid. 56. Ibid. 57. The exceptional rate was passed with article 97 of the law of December 19, 1926, Journal officiel de la république française: Lois et décrets (December 19, 1926): 13172. 58. René Poudevigne, “Les Femmes d’internés,” Journal des mutilés et réformés (January 8, 1927): 1. 59. René Poudevigne, “Les Aliénés de guerre,” Journal des mutilés et réformés (November 3, 1929): 2. 60. Article 118, Journal officiel de la république française: Lois et décrets (April 17, 1930): 4227. 61. Antoine Sapin, “Les Aliénés de guerre,” Journal des mutilés et réformés (August 24, 1930): 2. 62. Ibid.

218

Notes to Pages 140–146

63. Ibid. 64. Annex 4413, Journal officiel de la république française: Documents parlementaires: Chambre (1931): 123–24. 65. Annex 5928, Journal officiel de la république française: Documents parlementaires: Chambre: Session extraordinaire (1931): 416–17. 66. Law of the general budget for 1938, Journal officiel de la république française: Lois et décrets (January 1, 1938): 16. 67. Journal officiel de la république française: Débats parlementaires: Chambre (December 31, 1938): 1673. The proposition was to be printed as Annex 4476. 68. The prices of common household goods were listed each year in the Annuaire statistique de la ville de Paris. Prices for 1925 are found in the Annuaire statistique de la ville de Paris (1925– 1926): 813. 69. Salaries for Parisian and provincial workers to 1940 can be found in the Annuaire statistique de la France (1939): 170–73. 70. “Les Morts vivants,” Journal des mutilés et réformés (February 25, 1922): 1; Pierre Darmon, “Les Aliénés de guerre inconnus,” Journal des mutilés et réformés (February 20, 1926): 1. 71. For the story of missing soldiers, and in particular that of Anthelme Mangin, see JeanYves Le Naour, The Living Unknown Soldier, trans. Penny Allen (2002; New York: Metropolitan Books, 2004). 72. Darmon, “Les Aliénés de guerre inconnus,” 1. 73. In 1921, there was some question as to whether Anthelme should receive a pension. The minister of war suggested that without an identity or a history, Anthelme could not prove that he had ever been in the military. Throughout the 1930s, there continued to be a monetary incentive for claiming this living unknown soldier. See Paul Bringuier, “La Plus tragique énigme de la guerre: Le Soldat inconnu vivant,” Paris-Soir (Dimanche), January 19, 1936, page 10. This article is cited in Eugen Weber, The Hollow Years (New York: W. W. Norton, 1994), 12. 74. Bringuier, “La Plus tragique énigme de la guerre: Le Soldat inconnu vivant,” pages 1 and 10. 75. Amédée Chivot, “Le Mystérieux aliéné interné à l’asile de Rodez depuis huit ans retrouverat-il sa famille?” Journal des mutilés et combattants (June 14, 1931): 1. 76. Max Lafont, L’Extermination douce: La Mort de 40,000 malades mentaux dans les hôpitaux psychiatriques en France sous le régime de Vichy (Lyon: Éditions de l’Arefppi, 1987). 77. Paul Cassel, “Aliénation mentale après la guerre,” Journal des mutilés et réformés (November 25, 1922): 2. 78. Ibid. 79. Ibid. 80. For the history of that renovation, see Baruk, Patients Are People Like Us. 81. “Histoire de l’Hôpital Esquirol,” http://www.hopital-esquirol.fr/siteEsq1/histoire Esquirol.htm (accessed November 29, 2008).

Chapter Five 1. Marie-Thérèse Lacroix-Dupouy, Les Services ouverts dans les asiles: La Conception de l’hôpital psychiatrique; Le Dispensaire de prophylaxie mentale et le service social (Paris: Jouve & Cie, 1926), 75–78.

Notes to Pages 147–150

219

2. Édouard Toulouse, Les Causes de la folie: Prophylaxie et assistance (Paris: Société d’Éditions Scientifiques, 1896), 360. 3. The relationships between the mental hygiene movement and the broader efforts toward social hygiene in Third Republic France are discussed in Jean-Bernard Wojciechowski, Hygiène mentale et hygiène sociale: Contribution à l’histoire de l’hygiénisme, 2 vols. (Paris: Éditions L’Harmattan, 1997). 4. For the French public health movement, see Ann La Berge, Mission and Method: The Early Nineteenth-Century French Public Health Movement (New York: Cambridge University Press, 1992); Catherine Kudlick, Cholera in Post-Revolutionary Paris: A Cultural History (Berkeley: University of California Press, 1996); and David S. Barnes, The Making of a Social Disease: Tuberculosis in Nineteenth-Century France (Berkeley: University of California Press, 1995). 5. For the American mental hygiene movement, see Norman Dain, Clifford W. Beers: Advocate for the Insane (Pittsburgh: University of Pittsburgh Press, 1980), and Gerald N. Grob, The Mad among Us: A History of the Care of America’s Mentally Ill (New York: Free Press, 1994). 6. Édouard Toulouse, “L’Open-door en Écosse,” Revue de psychiatrie (September 1899): 261– 72, cited in Anne-Laure Simonnot, Hygiénisme et eugénisme au XXe siècle à travers la psychiatrie française (Paris: Éditions Seli Arslan, 1999), 56–60. The article in Revue de psychiatrie is an extended excerpt of Toulouse, Rapport au conseil général de la Seine sur l’assistance des aliénés en Angleterre et en Écosse, 1898. 7. Édouard Toulouse, Rapport sur les hôpitaux et services d’observation et de traitement, May 13, 1899, session of the General Council of the Seine, cited in Édouard Toulouse, “Le Service ouvert pour les malades mentaux,” La Prophylaxie mentale 28 (1931): 304 n. 2; Simonnot, 64. 8. For the asylum law of 1838, see Le Moniteur universel (July 7, 1838): 1–2. Many historians have commented on the law of 1838. For a discussion of the law’s genesis, see Jan Goldstein, Console and Classify (New York: Cambridge University Press, 1987), Chapter 8. 9. For biographical information about Toulouse, see Michel Huteau, Psychologie, psychiatrie, et société sous la troisième république: La Biocratie d’Édouard Toulouse (1865–1947) (Paris: L’Harmattan, 2002); L. Marchand, “Édouard Toulouse (1865–1947),” Annales médico­psychologiques 105:1 (1947): 359–60; André Plichet, “Nécrologie: Édouard Toulouse (1856– 1947),” La Presse médicale 55:1 (June 28, 1947): 442; and Paul Sivadon, “J’étais interne des asiles de la Seine, 1929–1934,” Actualités psychiatriques 2 (1981): 22–29. 10. Sivadon, 24. 11. Ibid. 12. See Antony Rodiet and André Fribourg-Blanc, La Folie et la guerre, 1914–1918 (Paris: Félix Alcan, 1930), 3–6. 13. See the Administration générale de l’Assistance publique à Paris, Compte moral et administratif de l’exercice 1920, présenté au conseil de surveillance de cette administration (Montévrain: Imprimerie Typographique de l’École d’Alembert, 1921), 126. 14. Colin Dyer, Population and Society in Twentieth-Century France (New York: Holmes & Meier, 1978), 58. 15. Ibid, 37, 62. 16. See the introduction by Justin Godart (minister of public health) to the 1932 Senate discussion regarding the asylum law of 1838, Journal officiel de la république française: Débats parlementaires: Sénat (1932): 1355–64.

220

Notes to Pages 150–154

17. Gordon Wright, France in Modern Times, 5th ed. (New York: W. W. Norton, 1995), 348. 18. Dyer, 75. 19. Théodore Simon, Rapport annuel des asiles de la Seine, 1933, page 9, cited in John Ward, “Le malade mental étranger durant l’entre-deux-guerres: Une double aliénation médico-administrative,” Actes de l’histoire et de l’immigration, November 2002, http://barthes.ens.fr/clio/ revues/AHI/articles/volumes/wrd.html (accessed November 29, 2008). 20. See Ward, cited in the previous note. 21. See Raoul Leroy, “Chronique: Considérations sur la restriction des services d’aliénés de Bicêtre et de la Salpêtrière,” Annales médico-psychologiques 80:1 (1922): 289–97. 22. See Toulouse’s report to the Société médicale des asiles de la Seine, entitled “Réorganisation de l’hospitalisation des aliénés dans les asiles de la Seine” (Paris: Imprimerie nouvelle, 1920), quoted in Wojciechowski, 2: 41. 23. “Actes administratifs: Création d’un comité d’hygiène mentale,” L’Informateur des aliénistes et des neurologistes 15:5 (1920): 130–31. 24. André Antheaume, “Chronique,” L’Informateur des aliénistes et des neurologistes 15:12 (1920): 341–42, and Wojciechowski, 2: 83–93. 25. Historians disagree about the pervasiveness of support for eugenics in French psychiatry. See Simonnot, 134–9, and Wojciechowski, 2: 118, 136–37, 164–69, 175–77. 26. Wojciechowski, 2: 133–37. 27. Toulouse did, however, become a consultant for progressive government ministers in the 1930s. 28. December 29, 1920, “Renvoi à la troisième commission d’une proposition de M. Frédéric Brunet relative à la création d’asiles pour malades atteints de psychopathies légères,” Bulletin municipal officiel (January 11, 1921): 247–48. Also reprinted as Frédéric Brunet, “L’Assistance des psychopathes non internables,” L’Informateur des aliénistes et des neurologistes 16:1 (1921): 19–24. 29. Brunet, “L’Assistance des psychopathes non internables,” 20. 30. July 6, 1921, meeting of the Seine General Council, Procès-verbaux des délibérations 149 (1921): 831–33. 31. “Informations diverses,” Le Temps, June 17, 1922, p. 3. 32. The service became administratively separate from Sainte-Anne in 1924, but in the 1930s, when it became clear that the service was not helping to reduce asylum overcrowding, the General Council of the Seine reduced its funding and began to consider reattaching it to the asylum. See Antony Rodiet, “La Grande Pitié des asiles d’aliénés parisiens,” Le Progrès médicale 32 (August 6, 1932): 1388. The service was ultimately reattached to the asylum in 1941. 33. Wojciechowski, 2: 21–31. 34. The service later formed an institute and added a school of mental prophylaxis. Toulouse’s service is described in numerous publications, including Édouard Toulouse, Georges Genil-Perrin, and René Targowla, “L’Organisation du service libre de prophylaxie mentale à l’asile Sainte-Anne,” March 27, 1922, meeting of the Société médico-psychologique, Annales médico-psychologiques 80:1 (1922): 338–60; Édouard Toulouse, “L’Hôpital psychiatrique ouvert et le centre de prophylaxie mentale de la Seine,” Annales médico-psychologiques 91:1 (1933): 472– 97; and Édouard Toulouse, Hôpital Henri-Rousselle (Paris: Imprimerie Chaix, 1929).

Notes to Pages 154–162

221

35. Suzanne Serin, “Une Enquête médico-sociale sur le suicide à Paris,” La Prophylaxie mentale 2 (1926): 230–35. 36. Toulouse, “L’Hôpital psychiatrique ouvert,” 480. 37. André Antheaume, “Chronique,” L’Hygiène mentale 21 (1926): 4. 38. Toulouse, Genil-Perrin, and Targowla, “L’Organisation du service libre,” 341. 39. Antheaume, “Chronique” (1926): 5. 40. Toulouse, “L’Hôpital psychiatrique ouvert,” 482–83. 41. Toulouse, Genil-Perrin, and Targowla, “L’Organisation du service libre,” 341. 42. Toulouse, “L’Hôpital psychiatrique ouvert,” 485. 43. See Toulouse, “L’Hôpital psychiatrique ouvert,” 485, and Antheaume, “Chronique” (1926): 11–12, which shows the open service’s proposed admissions fees for 1924–1926. For the law of 1893, see Journal officiel de la république française: Lois et décrets (July 18, 1893): 3681–84. 44. Toulouse, “L’Hôpital psychiatrique ouvert,” 486; Huteau, 199–200. 45. Toulouse, “L’Hôpital psychiatrique ouvert,” 487. 46. The focus of labs changed over the service’s history. This list is from 1929. 47. Toulouse, Hôpital Henri-Rousselle, 13–16. 48. René Charpentier, “Chronique: L’Hôpital psychiatrique,” Annales médico-psychologiques 81:1 (1923): 5–11. 49. René Charpentier, “Chronique: L’Hôpital Magnan,” Annales médico-psychologiques 81:1 (1923): 193–202. 50. Journal officiel de la république française: Lois et décrets (February 6, 1937): 1585–86. 51. Georges Daumézon, “De la nécessité d’un définition standard du service ouvert,” January 23, 1939, meeting of the Société médico-psychologique, Annales médico-psychologiques 97:1 (1939): 126–32. 52. Rayneau is quoted in Daumézon, “De la nécessité d’un définition standard du service ouvert,” 129. 53. Charpentier, quoted from the July 24, 1922, meeting of the Société médico­psychologique, 246. 54. December 23, 1922, meeting of the Société médico-psychologique, Annales médico­psychologiques 81:1 (1923): 56–64. 55. Ibid., 59. 56. Daumézon, “De la nécessité d’un définition standard du service ouvert,” 129. 57. For the early history of psychoanalysis in France, see, for example, Elisabeth Roudinesco, La Bataille de cent ans: Histoire de la psychanalyse en France, vol. 1, 1885–1939 (Paris: Éditions du Seuil, 1986). 58. See Huteau, cited earlier. 59. Lacroix-Dupouy, 75–78. 60. Ibid., 75. 61. Ibid., 77–78. 62. See Dora B. Weiner, The Citizen-Patient in Revolutionary and Imperial Paris (Baltimore: Johns Hopkins University Press, 1993), 252; Erwin H. Ackerknecht, “Political Prisoners in French Mental Institutions,” Medical History, 19 (1975): 251; and Index des établissements médicaux, published by La Presse médicale (Paris: Masson, 1929, 1939; A. Maretheux and L. Pactat, 1934).

222

Notes to Pages 162–165

63. Toby Gelfand, “Neurologist or Psychiatrist? The Public and Private Domains of JeanMartin Charcot,” Journal of the History of the Behavioral Sciences 46:3 (2000): 215–29. 64. Christopher G. Goetz, Michel Bonduelle, and Toby Gelfand, Charcot: Constructing Neurology (New York: Oxford University Press, 1995), 149. 65. See Françoise Barbier, “Historique du service de l’admission de l’hôpital Sainte-Anne (1867–1967),” thesis for the Paris Faculty of Medicine, 1969, p. 36, and Préfecture du département de la Seine, Direction des affaires départementales, Rapport sur le service des aliénés du département de la Seine (Paris: Imprimerie Nouvelle), which appeared annually. 66. Toulouse, Genil-Perrin, and Targowla, “L’Organisation du service libre,” 346–60. 67. Given the deaths of so many men in the war, it may not be surprising that first-time admissions of female patients outnumbered admissions of male patients after the war, reversing the prewar relationship. See Édouard Toulouse, Roger Dupouy, and Marcel Moine, “Statistique de la psychopathie,” Annales médico-psychologiques 88:2 (1930): 390–404. 68. See Marc Daniel Alexander, “The Administration of Madness and Attitudes toward the Insane in Nineteenth-Century Paris,” Ph.D. dissertation, Johns Hopkins University, 1976; Barbier, cited earlier. 69. Antony Rodiet, “La Situation des asiles de la Seine pendant la guerre et les transferts des aliénés des parisiens en province,” Le Progrès médical (October 25,1919): 428–29; see also idem, “Chronique: Les Aliénés transférés en province et la protection de leurs biens,” Annales médicopsychologiques 83:2 (1925): 129–32. 70. Henri Colin, “Chronique: L’Encombrement des asiles de la Seine,” Annales médico­psychologiques 82:2 (1924): 289–96. 71. Antony Rodiet, “Les Internements d’aliénés étrangers, à Paris, depuis la guerre,” Le Progrès médical (January 4, 1930): 18. 72. Ultimately, the French government established reciprocal agreements with other European states to help cover the costs of hospitalization. See Ward, cited earlier. 73. Octave Crouzon, “Dix ans de fonctionnement d’un service d’observation et de triage neuro-psychiatrique à la Salpêtrière (1923–1933),” Bulletin de l’Académie de Médecine (October 31, 1933): 285–89. 74. Ibid., 288. 75. Administration générale de l’Assistance publique à Paris, Compte moral et administratif de l’exercice 1926, présenté au conseil de surveillance de cette administration (Montévrain: Imprimerie Typographique de l’École d’Alembert, 1927), 12. See also Administration générale de l’Assistance publique à Paris, Procès-Verbaux des séances du conseil de surveillance pendant la session 1925–1926 (Montévrain: Imprimerie Typographique de l’École d’Alembert, 1927), 488–91. 76. Compte moral, 1926, 12. 77. André Antheaume, “Chronique,” L’Informateur des aliénistes et des neurologistes 18:1 (1922): 1–2. 78. Édouard Toulouse, Roger Dupouy, and Adolphe Courtois, “Les Services ouverts pour psychopathes,” La Prophylaxie mentale 8 (1932): 546. 79. Annick Ohayon, L’Impossible rencontre: Psychologie et psychanalyse en France, 1919–1969 (Paris: Éditions la Découverte, 1999), 32. 80. “Au cours d’un accès de folie un professeur de piano blesse sa femme et tente de se faire justice,” Le Matin, January 15, 1933, page 6. Also cited in Ohayon, 32.

Notes to Pages 165–168

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81. Ohayon, 32. In response, Toulouse countered that Ramon had committed his crimes two years after his treatment, but the damage had already been done. 82. Robert A. Nye shows how nineteenth-century psychiatrists used public fears about the dangerousness of madmen to reinforce their own professional and civic utility. See Nye, Crime, Madness, and Politics in Modern France: The Medical Concept of National Decline (Princeton: Princeton University Press, 1984), Chapter 7. 83. For these incidents, see Wojciechowski, 2: 105–19; Georges Daumézon, Cinquantenaire d’Henri-Rousselle, 1922–1972 (Rueil-Malmaison: Laboratoires Sandoz, 1973); Ohayon, 33–35. 84. Wojciechowski, 2: 106. 85. Ohayon, 35. 86. A range of opinions on the place of open services in the context of the law of 1838 were offered at professional society meetings and published in professional journals. See, for example, Toulouse, Genil-Perrin, and Targowla, “L’Organisation du service libre,” 346–60; July 24, 1922, meeting of the Société médico-psychologique, Annales médico-psychologiques 80:1 (1922): 241–57; and December 23, 1922, meeting of the Société médico-psychologique, Annales médico-psychologiques 81:1 (1923): 56–64. See also M. Legrain, “De quelques erreurs et abus dans l’application de la loi de 1838,” L’Hygiène mentale 22 (1927): 63–69; Édouard Toulouse, “Le Problème de la folie devant le Sénat,” La Prophylaxie mentale 6 (1930): 269–74; and Georges Heuyer, “À propos de la loi de 1838 et de son projet de révision,” Annales médico-psychologiques 97:2 (1939): 179–200. The journal L’Informateur des aliénistes et des neurologistes (the forerunner to L’Hygiène mentale) also published numerous opinions on the topic throughout the early 1920s. 87. Olivier Bernier makes this point in Fireworks at Dusk: Paris in the Thirties (Boston: Little, Brown, 1993). 88. Étienne Trillat notes that the political will to institute open services was not as strong as the will to battle certain diseases, such as tuberculosis. See Trillat, “Une Histoire de la psychiatrie au XXe siècle,” in Nouvelle Histoire de la Psychiatrie, ed. Jacques Postel and Claude Quétel (Paris: Dunod, 1994), 352. 89. Journal officiel de la république française: Lois et décrets (February 6, 1937): 1585–86. 90. The circular is reprinted in Michel Godfryd, Le Droit de la santé mentale par les textes (Thoiry: Éditions Heures de France, 2000), 209–11. In December 1938, Rucart issued another circular that supported hygienic goals. He ordered that free voluntary placement should be the preferred method of placement for non-dangerous indigents who required internment for their psychiatric conditions. With this circular to prefects, Rucart hoped to break the practice by which only paying patients were admitted voluntarily. See the Journal officiel de la république française: Lois et décrets (December 8, 1938): 13745–13746. 91. For the service at the Salpêtrière, see Crouzon, cited earlier. Statistics for the service at the Pitié were reported in a handwritten note dated January 29, 1937, from Laignel-Lavastine to M. Gaussen, archivist of the Assistance publique. 92. Toulouse, “L’Hôpital psychiatrique ouvert,” 482. Statistics through 1929 are also presented in Toulouse, Hôpital Henri-Rousselle. 93. Toulouse, “L’Hôpital psychiatrique ouvert,” 482. 94. Ibid., 487. 95. Ibid., 489. 96. Maxime Laignel-Lavastine and Georges d’Heucqueville, “Statistique du service de

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Notes to Pages 169–179

psychiatrie d’urgence de la Pitié: rôle des services ouverts des hôpitaux,” Annales médico­psychologiques 94:1 (1936): 451. 97. Godfryd, Le Droit de la santé mentale, 214–15. 98. Michel Godfryd, La Psychiatrie légale (Paris: Presses Universitaires de France, 1989), 13.

Epilogue 1. On the brief revival of Deschanel’s political career and his sudden death, see, for example, Jean Mélia, Paul Deschanel (Paris: Plon, 1924), 233–40; Adrien Dansette, Histoire des présidents de la République: De Louis-Napoléon Bonaparte à Charles de Gaulle (Paris: Le Livre du Contemporain, 1960), 230–31; and Thierry Billard, Paul Deschanel (Paris: Pierre Belfond, 1991), 249–62. 2. F. Boller, A. Ganansia-Ganem, F. Lebert, and F. Pasquier, “Neuropsychiatric Afflictions of Modern French Presidents: Maréchal Henri-Philippe Pétain and Paul Deschanel,” European Journal of Neurology 6 (1999): 133–36. 3. Benjamin Joseph Logre, “Le Syndrome d’Elpénor,” Le Monde, May 1, 1948, page 3. 4. The certificate is reprinted in its entirety in Pierre Rentchnick, Ces Malades qui font l’histoire (Paris: Plon, 1983), 214–15. 5. Ibid., 214. 6. Maurice Pignède and Paul Abély, “Séquelles lointaines des commotions cérébrales: Tableau clinique tardif post-commotionnel,” L’Encéphale 25 (1930): 436–43. 7. Ibid., 437. 8. Ibid. 9. Ibid., 438–39. 10. Ibid., 443. 11. On commemoration and memory in interwar France, see Daniel J. Sherman, The Construction of Memory in Interwar France (Chicago: University of Chicago Press, 1999). 12. For a small sampling of these critiques, see Emmanuel Régis and Angelo Hesnard, La Psychoanalyse des névroses et des psychoses (Paris: Félix Alcan, 1914), and Congrès des aliénistes et neurologistes de France et des pays de langue française, August 2–7, 1923, L’Encéphale 18 (1923): 597–603. 13. René Targowla, “L’État actuel du syndrome subjectif des traumatismes cranio-cérébraux chez les blesses de la Guerre 1914–1918,” Annales médico-psychologiques 94:2 (1936): 153–76. 14. Ibid., 168–69. 15. Ibid., 156. 16 Ibid., 168. 17. Pierre-Adolphe Chatagnon and Simone Jouannais, “Influence des événements de guerre sur les psychopathies,” December 18, 1939, meeting of the Société médico-psychologique, Annales médico-psychologiques 97:2 (1939): 610–17. 18. Ibid., 611. 19. Ibid., 611–12. 20. Ibid., 612–13. 21. Ibid., 615. 22. Jacques Vié, “Troubles psychopathiques en rapport avec les événements actuels,” December 18, 1939, meeting of the Société médico-psychologique, Annales médico-psychologiques 97:2 (1939): 621–26.

Notes to Pages 179–183

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23. Henri Beaudouin, “Événements de guerre et troubles mentaux,” December 18, 1939, meeting of the Société médico-psychologique, Annales médico-psychologiques 97:2 (1939): 618–21. 24. This idea of a hysterical culture is borrowed from Elaine Showalter, Hystories: Hysterical Epidemics and Modern Media (New York: Columbia University Press, 1997). 25. See Henri Baruk, Patients Are People Like Us: The Experiences of Half a Century in Neuropsychiatry, trans. Eileen Finletter and Jean Ayer (1976; New York: William Morrow, 1978), Chapter 7, and Henri Baruk, “Les Crises nerveuses généralisées: Séméiologie—Diagnostic—Conduite à tenir notamment en neuro-psychiatrie militaire,” Annales médico-psychologiques 102:2 (1944): 245–78. 26. Baruk, Patients Are People Like Us, 126. 27. Ibid. 28. Ibid., 127. 29. For a discussion of war-induced neuroses in World War II, see Hans Binneveld, From Shellshock to Combat Stress: A Comparative History of Military Psychiatry, trans. John O’Kane (Amsterdam: Amsterdam University Press, 1997), especially Chapter 6; Terry Copp and Bill McAndrew, Battle Exhaustion: Soldiers and Psychiatrists in the Canadian Army, 1939–1945 (Montreal: McGill-Queen’s University Press, 1990); Edgar Jones and Simon Wessely, “Psychiatric Battle Casualties: An Intra- and Interwar Comparison,” British Journal of Psychiatry 178 (2001): 242–47; Edgar Jones and Simon Wessely, Shell Shock to PTSD: Military Psychiatry from 1900 to the Gulf War (New York: Psychology Press, 2005), Chapter 4; Harold Merskey, “Post-Traumatic Stress Disorder and Shell Shock,” in A History of Clinical Psychiatry, ed. German E. Berrios and Roy Porter (New York: New York University Press, 1995), 494; Ben Shephard, A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century (Cambridge, Mass.: Harvard University Press, 2001), Chapters 13–15; and Pierre Lefebvre and S. Barbas, “L’Hystérie de guerre: étude comparative de ses manifestations au cours des deux derniers conflits mondiaux,” January 23, 1984, meeting of the Société médico-psychologique, Annales médico-psychologiques 142 (1984): 262–66. 30. Lefebvre and Barbas, “L’Hystérie de guerre,” 262–66. 31. Binneveld, 95. 32. See J. Sutter, H. Stern, and R. Susini, “Évolution du problème des psychonévroses de guerre,” Annales médico-psychologiques 105:2 (1947): 249–70, and idem, “Psychonévroses de guerre: Étude d’une centaine de cas personnels,” Annales médico-psychologiques 105:2 (1947): 496–524. 33. Max Lafont, L’Extermination douce: La Mort de 40,000 malades mentaux dans les hôpitaux psychiatriques en France sous le régime de Vichy (Lyon: Éditions de l’Arefppi, 1987), and Jean-Bernard Wojciechowski, Hygiène mentale et hygiène sociale: Contribution à l’histoire de l’hygiénisme, vol. 2 (Paris: Éditions L’Harmattan, 1997), 228. 34. See, for example, Henry Rousso, The Vichy Syndrome: History and Memory in France since 1944, trans. Arthur Goldhammer (1987; Cambridge, Mass.: Harvard University Press, 1991). 35. See Jean Demay, “The Past and the Future of French Psychiatry,” trans. Michel Vale, International Journal of Mental Health 16 (1987): 71–72. 36. For more on the role of French psychiatrists in the development of psychopharmacology, see the works of David Healy, including The Psychopharmacologists (New York: Altman, 1996), The Psychopharmacologists II (New York: Oxford University Press, 1999), The Psychopharmacolo-

226

Notes to Pages 183–186

gists III (New York: Oxford University Press, 2000), and The Creation of Psychopharmacology (Cambridge, Mass.: Harvard University Press, 2002), esp. 76–93. 37. There are numerous books on Lacan, and many other works that place him in the context of the history of French psychiatry. See, for example, Roudinesco, Jacques Lacan & Co.: A History of Psychoanalysis in France, 1925–1985, trans. Jeffrey Mehlman (Chicago: University of Chicago Press, 1990) and Martha Noel Evans, Fits and Starts: A Genealogy of Hysteria in Modern France (Ithaca: Cornell University Press, 1991). 38. Demay, “The Past and the Future of French Psychiatry,” 71–72. 39. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR, 4th ed., text revision (Washington, D.C.: American Psychiatric Association, 2000). The term was originally hyphenated (“post-traumatic stress disorder”), but the APA joined the first two words in the 4th edition of the DSM (“posttraumatic stress disorder”). The French have only gradually adopted the DSM as a research tool and clinical guide. See the work of Pierre Pichot, including “The French Approach to Psychiatric Classification,” British Journal of Psychiatry 144 (1984): 113–18, “DSM-III and Its Reception: A European View,” American Journal of Psychiatry 154 (1997): 47–54, and “The Diagnosis and Classification of Mental Disorders in French-Speaking Countries: Background, Current Views and Comparison with Other Nomenclatures,” Psychological Medicine 12 (1982): 475–92. 40. DSM-IV-TR, 463–68. 41. The disorder also has acute, chronic, and delayed-onset subclasses. The acute classification is given for symptoms lasting less than three months; the chronic classification is for symptoms lasting three months or more. Delayed-onset PTSD is specified when symptoms begin at least six months after the stressor. 42. The psychiatric literature on PTSD is voluminous. See, for example, Jennifer C. Jones and David H. Barlow, “The Etiology of Posttraumatic Stress Disorder,” Clinical Psychology Review 10 (1990): 299–328; Patricia B. Sutker, J. Mark Davis, Madeline Uddo, and Shelly R. Ditta, “War Zone Stress, Personal Resources, and PTSD in Persian Gulf War Returnees,” Journal of Abnormal Psychology 104 (1995): 444–52; and the excellent collection of articles that appeared in the Journal of Clinical Psychiatry 61 (2000), supplement 5. 43. Jones and Barlow, “The Etiology of Posttraumatic Stress Disorder.” 44. Edna Foa, “Psychosocial Treatment of PTSD,” Journal of Clinical Psychiatry 61, supplement 5 (2000): 43–48, discussion 49–51. 45. Jonathan Davidson, “Pharmacology of PTSD Treatment Options, Long-Term FollowUp and Predictors of Outcome,” Journal of Clinical Psychiatry 61, supplement 5 (2000): 52–56, discussion 57–59. 46. See Showalter, Hystories, cited earlier. The United States Research Advisory Committee on Gulf War Veterans’ Illnesses maintains that Gulf War syndrome was caused by exposure to nerve gas, nerve gas remedies, and insecticides. See http://www1.va.gov/rac-gwvi/docs/ GWIandHealthofGWVeterans_RAC-GWVIReport_2008.pdf (accessed November 26, 2008). 47. See Marc Bloch, Strange Defeat: A Statement of Evidence Written in 1940, trans. Gerard Hopkins (New York: W. W. Norton, 1999).

Selected Bibliography Primary Archival Sites Les Archives de l’Assistance Publique—Hôpitaux de Paris La Bibliothèque interuniversitaire de Médecine (BIUM), Paris Hoover Institution Library and Archives, Stanford, California Le Musée du Service de santé des armées, Val-de-Grâce, Paris National Library of Medicine, Bethesda, Maryland Archival Materials (All from Les Archives de l’Assistance Publique—Hôpitaux de Paris) Administration générale de l’Assistance publique à Paris. Compte moral et administratif, présenté au conseil de surveillance de cette administration. 1911–1940. Montévrain: Imprimerie Typographique de l’École d’Alembert. Administration générale de l’Assistance publique à Paris. Procès-Verbaux des séances du conseil de surveillance. Montévrain: Imprimerie Typographique de l’École d’Alembert. Registres des entrées—Salpêtrière. Conseil général de la Seine. Procès-verbaux des délibérations. 1921. Ministère de la Guerre. Statistique médicale de l’armée métropolitaine. 1914–1937. Paris: Imprimerie Nationale. Préfecture du département de la Seine, Direction des affaires départementales. Rapport sur le service des aliénés du département de la Seine. 1877–1925. Paris: Imprimerie Nouvelle.

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Newspapers L’Écho de Paris L’Éclair Le Figaro L’Humanité Le Journal Le Matin The New York Times Paris-Soir Le Temps

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Index Abély, Paul, 173, 174 Abrami, Léon, 111 Achille-Delmas, François, 178–79 Aimé, Henri, 50 alcoholism, 41, 46, 67, 78, 82, 89, 91, 175; reduction of, in postwar France, 88 Algeria, ethnopsychiatry in, 64–65 aliénés, 76, 88, 129, 130, 151, 163, 164, 167, 179; families and wives of, 133–34, 139–43, 144– 45; origin of term, 29. See also neuropsychiatric illnesses; pension law alienism, 29, 30, 31, 32. See also psychiatry alienists, 74, 75; collaboration of, with neurologists, 30, 31–32; criticism of, 30–31 Alsatians, effect of World War I on, 85–86 American Legion, 128 amnesia, 17, 53–54, 57, 65, 68, 173, 174; attempts to reunite amnesiac soldiers with families, 143 Annales médico-psychologiques, 74, 76, 157 Antheaume, André, 130 anxiety, 21, 26, 46, 59, 81, 86, 152, 172, 182, 189; concerning economic hardship, 90, 93, 146, 164, 165; management of, 185; and posttraumatic stress disorder, 185 arteriosclerosis, 175 Association amicable des médecins aliénistes, 166 asylums, 29, 34, 119, 151, 157, 164–65, 188; admissions to, as gauge of mental illnesses among civilians, 74–76, 77–78, 79, 87–89; conditions in, 147; financial burdens of, 163, 222n72; immigrant patients in, 150; overcrowding in, 89, 163, 220n32; post– World War I increase of inpatients in, 162,

222n67; transfer of patients from cities to provincial asylums, 162–63; veterans in, 127–28. See also individual asylums Audoin-Rouzeau, Stéphane, 80 Babinski, Joseph, 3, 4, 24, 34, 114, 120, 200n58; concept of pithiatism, 27, 34, 53, 106, 200n59; treatment recommendations for pithiatism and functional disorders (persuasive therapy), 38 Baillarger, Jules, 75 Ballet, Gilbert, 53, 57 Baruk, Henri, 145, 165, 180–81 battle hypnosis, 21, 53, 55–56, 69 Bayle, Antoine Laurent Jessé, 129 Beard, George Miller, 6 Beaudouin, Henri, 179 Beaussart, Pierre, 118 Becker, Annette, 80 Beers, Clifford, 148 Benon, Raoul-Louis, 66–67 Bicêtre asylum, 28, 96 Binet, Alfred, 166 Boisseau, Jules, 35; neuropsychiatric center of, 35–37 Breton, Jules-Louis, 130, 152 Briand, Marcel, 71, 209n37 Brunet, Frédéric, 153 Brunner, José, 51 case histories. See medical case histories Cassel, Paul, 144 Châlons-sur-Marne asylum, 140–41 Chamber of Deputies (France), 110–11, 112; as the “Blue Horizon,” 110

254

Charcot, Jean-Martin, 21–22, 27, 45, 48, 59, 91, 92, 162; and development of neurology, 30 Charenton–Saint-Maurice asylum, 128–32, 145, 181; name of, 215–16n17; as a “national” institution, 129; project to convert to maternity hospital, 129–31 Charpentier, René, 46, 157, 158 Chatagnon, Pierre-Adolphe, 176–78 Château de la Vallée-aux-Loups, 7 Chaslin, Philippe, 80 Chavigny, Paul, 50, 63 Chéron, Henry, 110, 111–12 civilians: direct effects of war on, 77–80, 84–87; effect of war on Alsatians, 85–86; post–World War I effects on, 188–89; role of emotions in, 75–76, 78; role of statistics in study of, 74–75; studies of, 73–79; and war-induced illnesses, 10–11, 15, 19, 71–73, 93–94, 176–82; war-induced melancholy in, 89–93. See also suicide Claude, Henri, 45, 120 clinics, private, 7–8, 193n41; treatments offered by, 7 Cohen, Deborah, 212n50 Colin, Henri, 115, 116, 130, 163 Commission of Civil and Military Pensions, 135–36, 141 Committee for Mental Hygiene, 152 commotional syndrome, 21, 52, 56–58, 69 Courbon, Paul, 85–86 Cox, Caroline, 215n16 Crouzon, Octave, 120, 164 Cygielstrejch, Adam, 76–77, 118 Damaye, Henri, 41, 46 degeneracy theory, 18, 62 Dejerine, Joseph Jules, 22–24 delirium, 41, 46, 82; “dreamlike delirium,” 53; emotive delirium, 179 dementia, precocious, 21, 82, 213n72; compared with dementia praecox, 26 depression, 13–14, 41, 46, 82 Deschamps, Baptiste, 41 Deschanel, Paul, 1–6, 8–9, 161, 170–71, 102n8, 191n1 Devaux, Albert, 26

Index

diagnostic categories, 43–44, 46–47, 51–61, 104–6, 121–22 Dide, Maurice, 35–36, 61 doctors, 43, 122; concern of, over portraying French army as weak, 49–50; diagnostic labels created by, 11; nationalistic attitude of French doctors, 25–26, 42, 49; power of, 9, 37; quest of, to understand the psychological impact of war, 10; role of, in discharge and pension decisions concerning soldiers, 100, 103–8, 187–88. See also neurologists; psychiatrists Doty, Madeleine Z., 80 Dowbiggin, Ian, 18, 62 Dumas, Georges, 39, 50, 54–55, 64 Dupouy, Roger, 46, 120 Dupré, Ernest, 57, 63; on the psychological effects of war, 108 Durkheim, Émile, 81–82; reexamination of work of, by Halbwachs, 83–84 Duval, Pierre, 2–3, 4 échelle de gravité (scale of severity), 104–6, 121–22 electrotherapy, 7, 39–40, 43; system of electric shocks (torpillage), 40–41 encephalitis lethargica, 68, 150, 168, 207n186 epidemic encephalitis. See encephalitis lethargica epilepsy, 31, 96, 108; hystero-epilepsy, 46, 95 Esquirol, Jean Étienne Dominique, 28, 129 etiology, of mental illnesses, 13, 32, 48, 53, 56, 64, 68, 73, 93, 106, 116, 184. See also neuropsychiatric illnesses, causes of ethnopsychiatry, 64–65 eugenics, 152, 220n25 Federation of Associations for Aid and Protection, 134 Fitzgerald, Zelda, 8 Foucault, Michel, 17, 28 France, 14–15, 16, 180, 186, 189; anti-German sentiment in, 25; casualties and deaths in, during World War I, 99, 126, 127; demographic changes in, 150; German occupation of, 182–83; immigration to, 150;

Index

medical training in, 31; mobilization of, for World War I, 99; post–World War I social and medical environment in, 149–53; regeneration of “human capital” in, 151–52; reorganization of healthcare organizations in, 151; suicide rates in, 84; traumatic memory in, 17. See also Alsatians, effect of World War I on; Paris Franco-Prussian War (1870–71), 74, 176 Freud, Sigmund, 159; interpretation of war neuroses by, 42–43, 201nn75–76; opposition of, to electrotherapy, 43; reception of work of, in France, 42, 159 Fribourg-Blanc, André, 66, 67, 87–89, 128, 214n3 functional disorders and illnesses, 9–10, 27, 68, 69, 202n88; belief in easily curability, 40; as hysteria, 21; increase of, during World War I, 45–46; names for, 21–22; symptoms of, 20 Fursac, Joseph Rogues de, 57 Gaupp, Robert, 51 General Council of the Seine, 153, 220n32 Genil-Perrin, Georges, 152, 166 Germany: psychiatry in, 21, 25–26, 43, 50–51, 56, 58; French nationalism against, 25–26, 50–51; pension neuroses in, 51, 59; psychoanalysis as “German theory,” 42; release of French prisoners of war from, 150; veterans’ pensions in, 16, 114, 212n50, 213n70; warinduced illnesses among soldiers of, 14, 50– 51, 181, 195n53 Gilles, André, 40, 45, 50 Godart, Justin, 103, 215n10 Goldstein, Jan, 18 Grasset, Joseph, 53, 107 Great Britain: psychiatry and neurology in, 6, 16, 20, 42, 48, 51, 55, 58, 65–66; war­induced illnesses among soldiers of, 14, 20, 48, 50, 51, 55, 65–66, 181–82; veterans’ pensions in, 110, 114, 212n50 grief, 80–81 guide-barème (disability table), 105–6, 113–14, 122 Gulf War syndrome, 185, 226n46 Halbwachs, Maurice, 83–84

255

Henri-Rousselle hospital, 157, 165, 166, 168 Hesnard, Angelo, 120; criticism of Freudian theory by, 42 hospitals, 29, 127, 215n4; “psychiatric” hospitals, 157–58; “psychopathic” hospitals, 154, 157, 169; versus asylums in pension law, 137–39. See also specific hospitals Hôtel-Dieu, 127 Huteau, Michel, 159 hydrotherapy, 7, 41 hysteria, 21–22, 31, 51, 120, 121, 180; culture of, 180, 225n24; “dismemberment” of, 47; distinction of, from epilepsy, 95; electric shocks as a cure for, 40–41; gender connotations concerning, 47, 48–49, 91, 202n100; hysterical “commotion,” 53; models of, 92– 93; prevalence of, among civilians, 91–92; prevalence of, among soldiers, 45, 47–48, 91, 93, psychological model of, 59–60; psychology of, 64; treatment of, 38 idiocy, 32 Imianitoff, Sara-Léa, 79, 84, 88 impôt du sang (blood tax), 110 Infirmerie spéciale, Paris, 57, 71, 87, 171, 179 Janet, Pierre, 23, 42, 174; psychological model of hysteria of, 59–60 Jones, Colin, 28 Joseph, Benjamin, 26 Jouannais, Simone, 176–78 Journal des mutilés et réformés, 109, 131, 134 Joyce, Lucia, 8 Kahn, Pierre, 43, 162 Kraepelin, Emile, 26 Lacan, Jacques, 183 Laënnec hospital, 127 Lafont, Max, 182, 184 Laignel-Lavastine, Maxime, 45, 120, 164–65 Laûx, Georges, 130, 131–32, 139 Le Figaro, 49, 50, 203n107 Le Page, René, 2–3 League of Mental Hygiene, 152–53 Lépine, Jean, 120 Léri, André, 45–46, 107, 120

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Lerner, Paul, 51 Les Invalides, 127, 215n9 les morts vivants (the living dead), 9, 126 L’Haÿ-les-Roses château (clinic), 7 Limoux, asylum at, 77 Logre, Benjamin Joseph, 26, 170–71 Louis XVIII, 102 Lugol, Georges, 110 Lunier, Ludger, 74–76, 90; influence of work of, 76; methodology of, 74, 76; weakness of key assumption of, 75 Magnan, Valentin, 89–90, 157 Mailhol clinic, 7 Mairet, Albert, 54; on the definition of “commotional syndrome,” 56–57 Maison-Blanche asylum, 126, 127, 179; case studies of women with mental disorders at, 176–78; open services of during World War I, 153, 154 maisons de santé, 7–8, 193n41 Malmaison sanatorium, 7, 193n40 Mangin, Anthelme, 143–44, 183, 218n73 manic-depressive psychosis, 26 Marie, Auguste, 68 Marie, Pierre, 45, 47, 106 Martimor, E., 116–17 Masse, Pierre, 110 Maudsley Hospital, 169 medical case histories: of “A.,” 63–64; of Alfred, 56; of “B.,” 95–99, 210n5; of Cr. Alphonse, 174–75; of “Haudry,” 54–55; of Jean Ch., 171–73; of L. J., 115–16; of Louis (first case), 51–52; of Louis (second case), 116–17; of M. B., 115; of Madame O., 81, 84; of Madame P., 158, 160–61; of Mademoiselle D., 71–72; of “O.,” 54; of “P.,” 78; of Pierre, 58; of “R.,” 20–24; of shell shock, 55 melancholy, war-induced, 89–93, 178–79; statistics concerning, 90–91 memory: collective and individual, 16–17; traumatic, 17, 173–74 “mental confusion,” 53–54 mental hygiene movement, 13, 17, 82, 128, 147–49, 152, 156, 166, 168–69, 188–89; and prophylactic approach to illness, 159–60; social outreach programs of, 148

Index

Meyer, Adolphe, 148 Mignot, Roger, 139 Milian, Gaston, 53, 55 military psychiatric and neurologic centers, 33–38 Millerand, Alexandre, 2 Ministry of Hygiene, Assistance, and Social Planning, 152 Minkowski, Eugène, 115, 116, 154 Mitchell, Silas Weir, 7 Montembault, Ernest, 46, 60, 63–64, 202n94 Morel, Bénédict-Augustin, 62 Myers, Charles S., 55, 204n132 mythomanic personality type, 63 Napoleon III, 102 Necker hospital, 127 neurasthenia, 6, 31, 193n38; prevalence of, among army officers, 65–66; symptoms of, 6; treatment of (rest cure), 7. See also Beard, George Miller; Mitchell, Silas Weir neurologists, 9–10, 18, 21, 24, 123; influence of, on pension law reform, 11–12; and overreporting of war hysteria, 47–48; reasons for participation of, in war effort, 26–28; role of, in the amended pension law (1929), 120–22. See also alienists, collaboration of, with neurologists; neuropsychiatric community neurology, 6, 14, 15, 27, 45, 126, 164, 174. See also neuropsychiatric community, the Neurology Society of Paris, 24, 27, 31, 34–35, 107, 113 neuropsychiatric centers, 35–37, 45; reports of hysteria in, 46; treatments provided by, 38–43 neuropsychiatric community, 28–32, 100, 174; debates among, concerning diagnostic labeling, 52–53; organization of, 32–38 neuropsychiatric illnesses, 32, 68–70; conversion of psychological symptoms to somatic symptoms, 66, 206n181; diagnostic labeling and classification of, 51–61, 121–22; newspaper coverage of, during World War I, 49–50, 203n107; prevalence of, 189–90; relationship of, to physical illnesses, 56, 58–

Index

59; relationship of, to World War I, 8–9, 19, 50–51, 186, 187; susceptibility to, 61–62; in women, 176–79, 186–87, 209n37, 222n67; and workplace injuries, 109, 212n44. See also neuropsychiatric illnesses, causes of; suicide; neuropsychiatric illnesses, prevalence of neuropsychiatric illnesses, causes of, 61–68, 121, 175; emotions, 61, 73–77, 78; environment, 62–63; heredity, 62, 64, 76; organic injury, 61; personality type, 63–64, 78–79; race, 64–65; social class, 65–66; traumatic memory, 173–74; and war, 66–68 neuropsychiatric illnesses, prevalence of: and the benefits of being sick, 189–90; of hysteria, 47–48, 49; of inherited defects, 85; of mental illness, 32, 75; of psychological trauma, 189; of shell shock, 15, 51, 189; of war neuroses, 44 neuropsychiatric services, proliferation of, 161–65; outpatient, 162. See also open psychiatric services nosology. See diagnostic categories Nye, Robert A., 223n82 obusite illness, 20–21 open psychiatric services, 13–14, 26, 115, 126, 146–47, 168–69, 189; advocates of, 152, 164; clientele of, 158–61; economic benefits of, 163–64; increase in admissions to open-service hospitals, 168; legislative hurdles concerning, 166–68, 223n88; naming of, 157– 58; opposition to, 165–66; in Paris, 153–57, 162, 183, 209n37, 220n32, 220n34; popularity of, 190; proper designation for patients of, 158–59; in Scotland, 148 Oppenheim, Paul, 58, 59 Paloque, A., 131–32 Parant, Victor, 25–26 Paris, 29; bombing of, 79–80; food prices in (1925), 142; suicide rates in, 84. See also open psychiatric services Paris Faculty of Medicine, 31 “patriotic excitation,” 90–91 pension law, 96–97, 144–45, 187–88, 210n8; amendments to 1919 pension law (1929),

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120–22; anger of psychiatrists over new pension law, 114–15, 139; Article 10 of 1919 pension law, 139; Article 55 of 1919 pension law, 144; Article 64 of 1919 pension law, 137; and codification of disability table (guidebarème), 105–6, 113–14, 122; and codification of injury and illness classifications (“scale of severity” [échelle de gravité]), 104– 6, 121–22; compensation of those diagnosed with pithiatism, 107, 113–14; complexity and confusion concerning, 101–3; correction of “marriage penalty” provision, 140–42; efforts to reform, 99–100; enactment of pension reform bill (1919), 112; interwar corrections to 1919 pension law, 139–42; and legal distinction between physical and psychological illnesses, 138–39, 144; “marriage penalty” of 1919 pension law, 136–37; opposition to “presumption of origin” clause, 117; patriotic response of legislators concerning pension law reform, 111–12; “presumption of origin” clause of, 115; provisions of pension reform bill, 112–14; rights of hospitalization under, 113, 213n65; rights of veterans to choose doctors under, 113, 213n64; rights of veterans to request medical evaluations under, 118, 214n83; significance of reform of, 142 pensions (military), 11–12, 122–23, 124, 144– 45; increase in pension requests for war­related neurosis, 114; lack of, for mentalillnesses sufferers, 12; pension neuroses in Germany, 51, 59; and various types of military discharges, 102–3, 211n21, 211n29; veterans’ demands concerning, 108–11; widows’ pensions, 134–36, 139–40. See also pension law Petit, André, 2–3, 4 petits mentaux, 153, 158, Piéron, Henri, 54 Pignède, Maurice, 173, 174 Pinard, Adolphe, 129, 130, 145 Pinel, Philippe, 21, 73–76; traitement morale of, 28 pithiatism, 22, 27, 34, 35, 47, 48, 92, 120–21; compensation of those diagnosed with, 107, 113–14; as diagnostic label, 52, 53; as equiv-

258

alent of malingering, 106, 128; negative moral connotations of, 63, 67; treatment of, 38, 106–7, 200n59 Pitié hospital, 127; open psychiatric services at, 164–65, 168 Poincaré, Henri, 149 Porot, Antoine, 65 posttraumatic stress disorder (PTSD), 184–86, 226n39; delayed-onset, 226n41; etiology of, 184–85; symptoms of, 184, 226n41; use of, as a retrospective diagnosis, 186 Poudevigne, René, 134–35, 138, 216n35 Prost, Antonie, 102–3, 109, 210n6, 211–12n38 psychiatrists, 9–10, 18, 21, 24, 84–85, 108, 123, 202n96; anger over and criticism by, of the new pension law (1919), 114–15, 118– 20; attitude of, toward the pension rights of veterans, 117–18; exploitation of public fears of “madmen” by, 165, 223n82; influence of, on pension law reform, 11–12, 187–88; reasons for participation of, in the war effort, 26–28; role of, in the amended pension law (1929), 120–22; treatments used by, 41. See also neuropsychiatric community psychiatry: British, 6, 16, 20, 42, 48, 51, 55, 58, 65–66; effect of World War I on, 12–14, 169; ethnopsychiatry, 64–65; French, 17–18, 23, 25–26, 28, 159; future of, 159; German, 21, 25–26, 43, 50–51, 56, 58; in the interwar period, 188; post–World War II changes in French psychiatry, 183–84; refounding of, on a medical model, 148. See also open psychiatric services; psychoanalysis psychoanalysis, 23, 42–43, 66, 68, 155 “psychoneurosis,” 53 Psychotherapeutic Establishment of Loiret, 162 psychotherapy, 7, 23, 42, 181 Puech, Louis, 111, 214n94 “railway spine,” 58 Ravaut, Paul, 57 Raviart, Georges-Édouard, 162 Rayneau, James, 162 Régis, Emmanuel, 33–34, 41, 43, 56, 58, 63; criticism of Freudian theory by, 42; on “mental confusion,” 53, 54

Index

Reinach, Joseph, 31 Rodez asylum, 143 Rodiet, Antony, 66, 67, 87–89, 128, 163, 214n3 Roudebush, Marc, 14, 41 Rougé, Calixte, 77–79, 90, 208n11 Rousselle, Henri, 153; Henri-Rousselle hospital, 157, 165 Roussy, Gustave, 26, 35–37; neuropsychiatric center of, 35–37, 39–40 Rucart, Marc, 168, 223n90 Sainte-Anne asylum, 33, 68, 71–72, 81–82, 89, 92, 127, 129, 144, 153–54, 156–57, 162, 165, 183, 209n37, 220n32 Salmon, Thomas, 51, 128, 148 Salpêtrière, 21–22, 30, 45, 80, 126, 162; admissions to, for hysteria, 91; open neuropsychiatric service of, 164, 168; treatment of soldiers after war’s end at, 127 Sapin, Antoine, 140–41 Sellier, Henri, 167–68 Serin, Suzanne, 82–83, 154 shell shock, 14–15, 15–16, 20, 48, 182; introduction of term, 55, 204n132; reported cases of, 55 Shephard, Ben, 215n16 Showalter, Elaine, 185–86, 193n38, 225n24 sleeping sickness. See encephalitis lethargica Simon, Théodore, 166 Sivadon, Paul, 149 Smith, Leonard, 80 Société médicale des asiles de la Seine, 166 Société medico-psychologique, 158, 176 Society of Legal Medicine, 117 soldiers, 58; alcoholism and depression among, 46; collection of medical statistics concerning, 43–51; frequency of humiliation of soldiers suffering hysteria by doctors, 48; hysteria among, 45, 47–48, 91, 93; medical assessments of, 104–6; neurological problems of, 47; neuropsychiatric disorders among American and British troops, 51; neuropsychiatric disorders among Austrian-German troops, 50–51; screening of, for psychological disorders, 32–33, 119–20; stigma of soldiers interned in asylums, 124–

Index

25; threats to masculinity of, 48–49; trauma among, 94; treatment of, for psychological disorders, 36, 37, 38–43. See also pensions; veterans’ associations; veterans, postwar plight of; veterans, postwar plight of wives and families of Sollier, Paul, 38, 57, 202n88; statistics of, on war-related neuroses, 44–45, 49–50 Strauss, Paul, 158, 159 suicide, 80–84; effect of wars and political crisis on, 83–84; influence of Durkheim on the study of, 81–82; statistics on, in Paris and France, 84 Suicide: A Study in Sociology (Durkheim), 81 syphilis, 175 Targowla, René, 174–76 Tavistock Clinic, 169 torpillage, 40–41 Toulouse, Édouard, 81, 82, 89, 130, 149, 152, 155–157, 159, 168–69, 174, 184, 189, 220n27; biocracy of, 152; on benefits of open psychiatric services, 163–64; opinion of, of asylums in France, 147; opposition to, 165–66; quest of, to improve institutional conditions, 147–49; retirement of, 166; support of, for birth control, 159–60. See also open psychiatric services trauma (traumatisme), 19, 58, 60–61, 189; among soldiers, 94; hystero-traumatism, 46, 202n94; “traumatic neuroses,” 58, 60 Trillat, Étienne, 223n88 Union nationale des mutilés et réformés, 109 United States: “psychopathic” hospitals in, 154, 157, 169; veterans’ hospitals in, 128, 215n16; veterans’ pensions in, 114 Vaillant, Édouard, 111 Val-de-Grâce military hospital, 37, 50, 66, 88, 115, 127; number of soldiers admitted to, 126, 214n3 Valentino, Charles, 109–10 Vallon, Charles, 98–99 veterans, postwar plight of, 124–26, 175–76, 187; amnesiacs, 142–44; institutional options for, 126–28; and the “marriage pen-

259

alty” of the 1919 pension law, 136–37; the “petits mentaux,” 153, 158; sequestered veterans as les morts vivants (the living dead), 9, 126. See also veterans, postwar plight of wives and families of veterans, postwar plight of wives and families of, 132–36; advocates for wives and families of veterans, 134–36; distance of, from interned loved ones, 132–33; economic issues, 134–36; social scars of, resulting from internment, 132; widows’ pensions, 134–36, 139–40, 217n38, 217n57 veterans’ associations, 108–11, 125, 211–12n38; political influence of, between wars, 109; position of, on pensions, 109–11; unification among, 109Vié, Jacques, 179 Ville-Évrard asylum, 115, 116, 126; open psychiatric services at, 153, 154 Villejuif asylum, 115, 116, 126, 149 Vincent, Clovis, 40–41 Voivenel, Paul, 26 Wallon, Henry, 98 war, psychological trauma of, 8–9, 15, 32, 108, 176–82; among different countries, 50–51 “war neurosis,” 21, 107, 114, 178. See also Freud, Sigmund, interpretation of war neuroses by Widal, Fernand, 4 Wiser, William, 9 World War I, 69, 163; effect of, on psychiatry, 12–14; frequency of functional disorders in, 45–46, 51; historiography of veterans of, 16; psychological stress on civilians in, 10–11, 15, 19, 71–73, 93–94, 186–87; psychological stress on soldiers in, 8–9, 19, 50–51, 186, 187 (see also shell shock); role of, in genesis of illness, 24–25, 66–67 World War II, 69, 145; anxiety and depression during “phony war,” 178; medical centers for treatment of psychological disorders during, 179–80; psychological stress on civilians during, 176–82; stress-induced somatic disorders caused by, 181–82; symbolic value of psychological symptoms suffered by soldiers of, 181