Virtually all of the physicians of the eighteenth century acknowledged the proximity of mania and melancholia. Several, however, refused to call them two manifestations of the same disease. Many observed a succession without perceiving a symptomatic unity. Sydenham prefers to divide the domain of mania itself: on one hand, ordinary mania—due to "an overexcited and too rapid blood"; on the other, a mania which, as a general rule, "degenerates into stupidity." The latter "results from the weakness of the blood which too long a fermentation has deprived of its most spirituous parts." Even more often, it is acknowledged that the succession of mania and melancholia is a
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phenomenon either of metamorphosis or of remote causality. For Joseph Lieutaud, a melancholia that lasts a long time and whose delirium is exacerbated loses its traditional symptoms and assumes a strange resemblance to mania:
"the last stage of melancholia has many affinities with mania." But the status of this analogy is not elaborated. For Dufour, the link is even looser: it is a remote causal connection, melancholia being able to provoke mania, as well as "worms in the frontal sinuses, or dilated or varicose vessels." Without the support of an image, no observation succeeded in transforming the evidence of succession into a symptomatic structure that was both precise and essential.
Of course the image of flame and smoke disappeared in Willis's successors; but it was still by images that the work of organization was accomplished—images increasingly functional, more firmly fixed in the great physiological themes of circulation and heating, increasingly remote from the cosmic figures Willis had borrowed them from. For Boerhaave and his commentator Gerard van Swieten, mania formed quite naturally the highest degree of melancholia—not only following a frequent metamorphosis, but as the result of a necessary dynamic sequence: the cerebral liquid, which stagnates in the melancholic, becomes agitated after a certain time, for the black bile that fills the viscera becomes by its very immobility "bitterer and more malignant"; there then form in it more acid and subtler elements which, carried to the brain by the blood, provoke the maniac's great agitation. Mania is thus distinguished from melancholia only by a difference of degree: it is its natural consequence, it results from the same causes, and is ordinarily treated by the same remedies. For Friedrich Hoffmann, the unity of mania and melancholia is a natural effect of the laws of movement and shock; but what is pure mechanics on the level of principles becomes dialectics in
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the development of life and of disease. Melancholia, in effect, is characterized by immobility; in other words, the thickened blood congests the brain where it accumulates;
where it ought to circulate, it tends to stop, immobilized by its heaviness. But if this heaviness retards movement, it also makes the shock more violent at the moment it occurs; the brain, the vessels by which it is traversed, its very substance, more violently jarred, tend to resist more, therefore to harden, and by this hardening the thickened blood is sent back more energetically; its movement increases and it is soon caught up in that agitation which is mania. We have thus passed quite naturally from the image of an immobile congestion to images of dryness, of hardness, of rapid movement, and this by a sequence in which the principles of classical mechanics are at every moment influenced, deflected, distorted by a fidelity to iconographic themes which are the true organizers of this functional unity.
Subsequently other images will be added, but will no longer play a constitutive role; they will function only as so many interpretive variations upon the theme of a previously acquired unity. Witness for example the explanation Spengler proposed for the alternation between mania and melancholia, borrowing its principle from the electric battery. First there is a concentration of nervous power and of its fluid in a certain region of the system; only this sector is agitated, all the rest is in a state of sleep: this is the melancholic phase. But when it reaches a certain degree of intensity, this local charge suddenly expands into the entire system, which it agitates violently for a certain time, until its discharge is complete: this is the manic episode. At this level of elaboration, the image is too complex and too complete, it is borrowed from a model too remote to have an organizing role in the perception of a pathological unity. It is, on the contrary, suggested by that perception, which
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itself is based on unifying, though much more elementary, images.
It is these images which are secretly present in the text of James's Dictionary, one of the first in which the manic-depressive cycle is given as an observed phenomenon, as a unity easily perceived by an unprejudiced scrutiny. "It is absolutely necessary to reduce melancholia and mania to a single species of disease, and consequently to consider them in one and the same glance, for we find from our experiments and our day-to-day observations that one and the other have the same origin and the same cause. . . . The most exact observations and our daily experience confirm the fact, for we see that melancholics, especially those in whom the disposition is inveterate, easily become maniacal, and when the mania ceases, the melancholia begins again, in such a way that there is a passage and return from one to the other after certain periods of time."11 What was constituted, in the seventeenth and eighteenth centuries, under the influence of images, was therefore a perceptual structure, and not a conceptual system or even a group of symptoms. The proof of this is that, just as in a perception, qualitative transitions could occur without affecting the integrity of the figure. Thus William Cullen would discover in mania, as in melancholia, "a principal object of delirium"—and, inversely, would attribute melancholia to "a drier and firmer tissue of the brain's medullary substance."
The essential thing is that the enterprise did not proceed from observation to the construction of explanatory images; that on the contrary, the images assured the initial role of synthesis, that their organizing force made possible a structure of perception, in which at last the symptoms could attain their significant value and be organized as the visible presence of the truth.
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II. Hysteria and Hypochondria
Two problems arise where these are concerned.
1. To what degree is it legitimate to treat them as mental diseases, or at least as forms of madness?
2. Are we entitled to treat them together, as if they constituted a virtual couple, similar to that formed quite early by mania and melancholia?
A glance at the classifications is enough to convince us; hypochondria does not always appear beside dementia and mania; hysteria is very rarely found there. Felix Plater mentioned neither one among the lesions of the senses; and at the end of the classical period, Cullen still catalogued them in another category than that of the vesanias: hypochondria among the "adynamias, or diseases which consist of a weakness or a loss of movement in the vital or animal functions"; hysteria among "the spasmodic affections of the natural functions."
Moreover, in nosographic charts one rarely finds these two diseases grouped in a logical proximity, or even combined in the form of an opposition. Sauvages classifies hypochondria among the hallucinations—"hallucinations that concern only the health"—hysteria among the forms of convulsion. Linnaeus employs the same distinctions. Are they not both faithful to the teaching of Willis, who had studied hysteria in his book De morbis convulsivis and hypochondria in the section of De anima brutorum which dealt with diseases of the head, giving it the name of passio colica? Here it is certainly a question of two quite different diseases: in one case, the overheated spirits are subject to a reciprocal pressure which may give the impression that they are exploding—provoking those irregular or preternatural movements whose insane aspect constitutes hysterical convulsions. On the contrary, in passio colica, the spir-
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its are irritated because of a matter that is hostile and inappropriate to them (infesta et improportionnata); they then provoke disturbances, irritations, corrugationes in the sensitive fibers. Willis therefore advises us not to
be surprised by certain analogies of symptoms: certainly, we have seen convulsions produce pains as if the violent movement of hysteria could provoke the sufferings of hypochondria. But the resemblances are deceptive. "The substance is not the same, but a little different."
But beneath these fixed distinctions of the nosographers, a slow labor was being performed which tended increasingly to identify hysteria and hypochondria, as two forms of one and the same disease. In 1725 Richard Blackmore published a Treatise of the Spleen and Vapours, or Hypochondriacal and Hysterical Affections; in it the two illnesses were defined as two varieties of a single affection-either a "morbific constitution of the spirits" or a "disposition to leave their reservoirs and to consume themselves." For Whytt, in the middle of the eighteenth century, the identification was complete; the system of symptoms is henceforth identical: "An extraordinary sensation of cold and heat, of pains in several parts of the body; syncopes and vaporous convulsions; catalepsy and tetanus; gas in the stomach and intestines; an insatiable appetite for food;
vomiting of black matter; a sudden and abundant flow of clear, pale urine; marasma or nervous atrophy; nervous cough; palpitations of the heart; variations in the pulse; periodic headaches; vertigo and dizzy spells; diminution and failure of eyesight; depression, despair, melancholia or even madness; nightmares or incubi."
Moreover, during the classical period hysteria and hypochondria slowly joined the domain of mental diseases. Richard Mead could still write apropos of hypochondria:
"It is an illness of the whole body." And we must restore its true value to Willis's text on hysteria: "Among the diseases
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of women, hysterical affection is of such bad repute that like the semi-damnati it must bear the faults of numerous other affections; if a disease of unknown nature and hidden origin appears in a woman in such a manner that its cause escapes us, and that the therapeutic course is uncertain, we immediately blame the bad influence of the uterus, which, for the most part, is not responsible; and when we are dealing with an inhabitual symptom, we declare that there is a trace of hysteria hidden beneath it all, and what has so often been the subterfuge of so much ignorance we take as the object of our treatment and our remedies." With all due regard to the traditional commentators on this text, which is inevitably cited in any study on hysteria, it does not mean that Willis suspected the absence of an organic basis in symptoms of hysterical affection. He merely says, and in an explicit way, that the idea of hysteria is a catchall for the fantasies, not of the person who is or believes himself ill, but of the ignorant doctor who pretends to know why. Nor does the fact that hysteria is classified by Willis among diseases of the head indicate that he considered it a disorder of the mind; but only that he attributed its origin to a change in the nature, the origin, and the initial course of the animal spirits.
However, at the end of the eighteenth century, hypochondria and hysteria figured, almost without dispute, on the escutcheon of mental disease. In 1755 Alberti published at Halle his dissertation De morbis imaginarus hypochondriacorum; and Lieutaud, while defining hypochondria by its spasms, recognized that "the mind is affected as much as and perhaps more than the body; hence the term hypochondriac has become almost an offensive name avoided by physicians who would please." As for hysteria, Joseph Raulin no longer ascribes to it any organic reality, at least in his basic definition, establishing it from the start in a pathology of the imagination: "This disease in which women invent,
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exaggerate, and repeat all the various absurdities of which a disordered imagination is capable, has sometimes become epidemic and contagious."
There were thus two essential lines of development, during the classical period, for hysteria and hypochondria. One united them to form a common concept which was that of a "disease of the nerves"; the other shifted their meaning and their traditional pathological basis—sufficiently indicated by their names—and tended to integrate them gradually into the domain of diseases of the mind, beside mania and melancholia. But this integration was not achieved, as in the case of mania and melancholia, on the level of primitive qualities, perceived and imagined in their iconographic values. We are dealing here with an entirely different type of integration.
The physicians of the classical period certainly tried to discover the qualities peculiar to hysteria and hypochondria. But they never reached the point of perceiving that particular coherence, that qualitative cohesion which gave mania and melancholia their unique contour. All qualities were contradictorily invoked, each annulling the others, leaving untouched the problem of what was the ultimate nature of these two diseases.
Often hysteria was perceived as the effect of an internal heat that spread throughout the entire body, an effervescence, an ebullition ceaselessly manifested in convulsions and spasms. Was this heat not related to the amorous ardor with which hysteria was so often linked, in girls looking for husbands and in young widows who had lost theirs? Hysteria was ardent, by nature; its symptoms referred more easily to an image than to an illness; that image was drawn by Jacques Ferrand, at the beginning of the seventeenth century, in all its material precision. In his Maladie d'amour ou melancholie erotique, he declared that women were
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more often distracted by love than men; but with what art they could dissimulate it! "In which their mien is similar to alembics featly resting upon cylinders, without one's being able to see the fire from without, yet if one looks beneath the alembic, and places one's hand upon a woman's heart, one will find in both places a fiery furnace." An admirable image, in its symbolic weight, its affective overtones, and the referential play of its imagery. Long after Ferrand, one finds the qualifying theme of humid heat used to characterize the secret distillations of hysteria and of hypochondria; but the image yielded to a more abstract motif. Already in Nicolas Chesneau, the flame of the feminine alembic had grown quite colorless: "I say that the hysterical affection is not a simple one, but that we understand by this name several diseases caused by a malign vapor which arises in some way or other, is corrupted, and undergoes an extraordinary effervescence." For others, on the contrary, the heat rising from the hypochondriac regions is completely dry: hypochondriacal melancholia is a "hot, dry" illness, caused by "humors of the like quality." But some perceived no heat in either hysteria or hypochondria: the quality peculiar to these maladies was on the contrary languor, inertia, and a cold humidity like that of the stagnant humors: "I think that these affections [hypochondriacal and hysterical], when they last for some time, come from the fibers of the brain and the nerves when they are slack and therefore feeble, without action or elasticity; as a consequence of which the nervous fluid is impoverished and without force."12 There is probably no text that bears better witness to the qualitative instability of hysteria than George Cheyne's book The English Malady: according to Cheyne, the disease maintains its unity only in an abstract manner; its symptoms are dispersed into different qualitative regions and attributed to mechanisms that belong to each of these regions in its own right. All symptoms of
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spasm, cramp, and convulsion derive from a pathology of heat symbolized by "harmful, bitter, or acrimonious vapors." On the contrary, all psychological or organic signs of weakness—"depression, syncopes, inactivity of the mind, lethargic torpor, melancholia, and sadness"—manifest a condition of fibers which have become too humid or too weak, doubtless under the effect of cold, viscous, thick humors that obstruct the glands and the vessels, serous and sanguine alike. As for paralyses, they signify both a chilling and an immobilization of the fibers, "an interruption of vibrations," frozen so to speak in the general inertia of solids.
It was as difficult for the phenomena of hysteria and hypochondria to find a place within the compass of qualities as it was easy for mania and melancholia to be established there.
The medicine of movement was just as indecisive in dealing with them, its analyses just as
unstable. It was quite clear, at least to any perception that did not reject its own images, that mania was related to an excessive mobility;
melancholia, on the contrary, to a diminution of movement. For hysteria and for hypochondria as well, the choice was a difficult one. Georg Ernst Stahl opts instead for an increasing heaviness of the blood, which becomes so abundant and so thick that it is no longer capable of circulating regularly through the portal vein; it has a tendency to stagnate, to collect there, and the crisis is a result "of the effort it makes to effect an issue either by the higher or the lower parts." For Boerhaave, on the contrary, and for Van Swieten, hysterical movement is due to an excessive mobility of all the fluids, which become so volatile, so inconsistent, that they are agitated by the least movement: "In weak constitutions," Van Swieten explains, "the blood is dissolved; it barely coagulates, the serum is thus without consistency, without quality; the lymph resembles the se-
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