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Related Topics
Mad TravelersReview - Mad Travelers
Reflections on the Reality of Transient Mental Illness
by Ian Hacking
Harvard University Press, 1998
Review by Rachel Cooper
Sep 1st 1999 (Volume 3, Issue 35)

Fugue, the disorder that afflicted the mad travellers of Hacking's title, is best described in the words of Philippe Tissé, the doctor-hero of the book. As he describes it, the French fugue epidemic of the late nineteenth-century all began "one morning last July when we noticed a young man of twenty-six crying in his bed in Dr. Pitres's ward. He had just come from a long journey on foot and was exhausted, but that was not the cause of his tears. He wept because he could not prevent himself from departing on a trip when the need took him; he deserted family, work, and daily life to walk as fast as he could, straight ahead, sometimes doing 70 kilometres a day on foot, until in the end he would be arrested for vagrancy and thrown in prison."

In Mad Travelers Hacking uses fugue as a case study to examine why it is that some mental disorders appear to thrive only at a particular place and time, or to be, as he puts it, "transient". Hacking suggests that plausible examples of other transient mental disorders include multiple personality disorder, anorexia nervosa and pre-menstrual syndrome. In all these cases we feel that patients really suffer from something, and yet the recent emergence of the disorder and the extent to which it appears culturally shaped make us hesitate when it comes to saying whether the disorder is "real".

Hacking's key contribution to understanding transient mental disorders is his metaphor of the ecological niche. Like biological organisms, Hacking suggests, transient mental disorders can only flourish within a particular environment. While organisms depend on food supplies and breeding sites, mental disorders need a medical community that will recognise them, and a contemporary culture that creates space for them between healthy, virtuous activities on the one hand, and vicious, criminal ones on the other. In the 1890s France provided the perfect environment for fugue. Police controls meant that wandering men would soon be picked up, and the medical community was happy to recognise fugue as a sub-type of either epilepsy or hysteria. At the same time cultural fascination with tourism and vagrancy allowed fugue to thrive in the ambiguous space between.

Hacking's idea that a disease may need an ecological niche makes good sense. It is undeniable that many physical disorders only flourish within a particular social environment - without heroin there would be no heroin addiction, if people didn't keep pigeons there would be no Pigeon Fancier's Lung. It is plausible that mental disorders may also require specific environments. Having said this, I have reservations about Hacking's use of fugue as an example of a transient mental disorder. Hacking claims that fugue, as a significant mental disorder, existed only in France between 1887 and 1909. He notes that fugue has been included in the Diagnostic and Statistical Manual of Mental Disorders (D.S.M.), the official classification system of the American Psychiatric Association, since 1980 but dismisses this as the result of political wangling by the proponents of multiple personality disorder. I question Hacking's claim that fugue died in 1909. Fugue was included as a diagnosis in the first D.S.M., published in 1952, and in its predecessor, the 1945 Statistical Manual for the Use of Hospitals for Mental Diseases (National Committee for Mental Hygiene). Its inclusion in these taxonomies cannot be attributed to the 1970s and 80s fights over multiple personality disorder. Moreover, the current D.S.M. (1994) estimates that today 0.2% of the general population meet the criteria for fugue, this compares with 0.2-2% for schizophrenia. If these figures are correct then fugue is a fairly rare disorder, but still very much alive and kicking.

Even if my scepticism as to whether fugue should be considered a transient mental disorder proves well founded, the idea that some mental disorders (even if not fugue) require an ecological niche is independently plausible, and the accounts of fugue included in the book make fascinating reading. Mad Travelers contains good material. The book is, however, less polished than Hacking's earlier work. Copies of primary sources are often presented without comment. In some cases a commentary would have been helpful; accounts of experiments in which the subject is hypnotised to associate "Vice" with pressure on his right knee and "Virtue" with pressure on his left make ghoulish reading, but the reader is given no clue as to why anyone would want to perform them in the first place.
 

Rachel Cooper is a lecturer in philosophy at Bristol University, England. She has research interests in the philosophy of science, especially psychiatry, and in 20th century history of psychiatry.


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