Hysteria, Mania, Gender

History of Psychiatry
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Mania, Hysteria and Gender in Lower Austria, 1891-1905

Edward Shorter
History of Psychiatry 1990; 1; 3
DOI: 10.1177/0957154X9000100102
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HIStory ofPqychwtw, 1 ( 1990),33-31. Prtnted ill England
Mania, Hysteria and Gender

in Lower Austria, 1891-1905
EDWARD SHORTER*
The history of psychiatric symptoms is of interest because it stands at the

intersection of biology and culture. Some psychiatric diseases are genetically
determined, and the push to illness is ultimately organic, coming from as yet
unknown proteins coded by the genes. Others seem to arise from stress. But
before illness becomes manifest in either case, the patient’s mind must produce
symptoms. If an underlying organic depression, let us say, is to become clinically
evident, the patient must first think depressed thoughts, or be unable to go to
sleep, or lose the ability to concentrate, all mental signs of depression.
As individuals form psychiatric symptoms in their minds, what particular
symptoms do they chose? Unceasing stomach pain or having fits on the carpet?
Individuals respond to models offered by the culture of what represents ’legiti-
mate’ disease. Their minds do not chose symptoms randomly but in response to
cultural notions of what is appropriate for presenting distress. The culture
imposes a template, or model, for making one’s inner distress evident to others, or
for bringing it to the doctor.
Thus the social historian of psychiatry must pursue three separate narratives:
one, that of underlying biology; second, the sto:y of the stresses and life experi-
ences of individual patients; third, the story of changes in the models which the
culture holds out for the communication of inner distress. We might imagine
these three separate stories as the three angles of a triangle. In the interior of the
*
Department of History, University of Toronto, Toronto, Canada MSS 1AI.
For their criticisms of an earlier version of this paper I should like to thank Prof. Jacalyn Duffin, MD,
Prof. Dr med. Eberhard Gabriel, Dr Edward Hare, MD, Dr med. Albrecht Hirschmuller, Dr Harold
Merskey, MD, Dr Mark Micale, Dr Rainer Munz, Dr Roy Porter, Prof. Dr Reinhard Spree, Dr Bruce M.
Sutton, MD, and Dr Walter Vandereycken, MD.
1This concept of ’triangle’ differs somewhat from the ’biopsychosocial’ model that George L. Engel has
presented for understanding disease. (’The need for a new medical model: a challenge for biomedicine’,
Science, clxxxxvi [8 April, 1977], 129-136.) In the triangle, ’psycho’ and ’social’ commingle at two
separate points: at ’personal life history’ and at ’cultural representations’. The triangle model has the
advantage of permitting us clearly to disentangle the stressful factors in an individual’s life history from the
cultural forms available to him or her for expressing psychic distress.

4
triangle are the actual psychiatric symptoms, and their history. But this history
may be shaped by changing any of the three sides: by demographic changes which
alter the composition of the population that is biologically at risk; by social
changes which increase or decrease the pressures upon, let us say, young women,
since they occupy such a prominent role here; and by cultural changes which
modify the kind of behaviour that is expected of individuals. The image of the
dynamic ’New Woman’ of the 1920s, for example, plays an obvious role in the
the hysterical paralyses that were once quite common among young
decline of
women2: the new woman, who rode motorcycles and smoked in public, simply
did not develop a paralysis as a legitimate way of communicating her distress.
The subject of this article is ’hysterical insanity’ and mania in Austrian asylums
at the turn of the century. I have chosen these two disorders - one a cultural
construct, the other a real disease - because of the major psychiatric illnesses they
seem to be the most ’plastic’, the most subject to cultural modifications.3 As we
observe them we should be able to define the particular shape of the triangle at the
fin-de-siecle among both the lower and middle classes of Central Europe, or at least
in the area around Vienna.
Gender is a particular concern of this article. Mania and hysterical insanity
should be able to give some insight into the relationship between gender, the
formation of psychiatric symptoms (what the patient brings to the doctor), and
the doctor’s diagnosis of those symptoms as a psychiatric disease. The role of
gender is evident at each point in the triangle: in the differing physical experiences
of men and women, in the stresses each experiences, and in the models that the
surrounding culture extends to each for communicating distress.
Between 1891 and 1905 forty-four patients were admitted to the provincial
asylum of Kierling-Gugging, just to the north of Vienna, with a diagnosis of one of
the above-mentioned ’plastic’ psychoses.4(See Table 1) They formed a tiny
portion of the thousands of patients who passed through Kierling-Gugging over
2
See Shorter, ’Paralysis: the rise and fall of a "hysterical" symptom’, Journal of Social History, xix
(1986),549-582.
3
On the relative stability in the form and content (as opposed to frequency) of psychotic depression and
of schizophrenia over fairly long periods of time, periods that include dramatic upheaval in the surround-
ing world, see Heinrich Kranz, ’Das Thema des Wahns im Wandel der Zeit’, Fortschritte der Neurologie
und Psychiatrie, xxiii (1955), 58-72; Hermann Lenz, Vergleichende Psychiatrie: Eine Studie uber die
Beziehung von Kultur, Sozsologie und Psychopathologie (Vienna: Maudrich, 1964); and J. Glatzel, ed.,
Gestaltwandel psychiatrischer Krankheitsbilder (Stuttgart: Schattauer, 1973), esp. the essay by W. Blanken-
burg & A. Zilly, ’Gestaltwandel im schizophrenen Wahnerleben?’, 129-143.
4
I am grateful to Hofrat Dr Alois Marksteiner, director of the Niederosterreichisches Landeskrank
enhaus Gugging, for permission to work in the archives of this institution. On its history see Marksteiner
& R. Danzinger, Gugging: Versuch einer Psychiatriereform (Salzburg: Verlag der Arbeitsgemeinschaft für
Verhaltensmodifikation, 1985). Kierling-Gugging was selected for study simply because its records have
survived, a rarity among Viennese psychiatric facilities. In my search of these records for patients with
affective disorders and hysteria, I excluded all those who had died in the asylum, on the grounds that their
symptoms may have been caused by an organic disease, all those over 55 at admission on the same grounds,
and all those with an intercurrent diagnosis of alcoholism. While I have included all cases of mania and
manic-depressive disorder that met the above criteria, I omitted some cases of ’hysteria’ which, upon an
initial reading of the chart, sounded more like misdiagnosed instances of schizophrenia.

5
TABLE 1. Cases ofhysteria, mania and manic-depressive illness admitted to
Kierling-Gugging, 1891-1905 (N 44) =
this period. Of these 44, ten women and no men received the diagnosis of hysteria
or hysterical insanity, 15 women and 4 men were diagnosed with mania, and 14
women and 1 man with ’circular psychosis’, a disease entity that would towards
the end of this period be renamed ’manic-depressive insanity’. Thus among these
psychiatric illnesses that are highly subject to cultural modification we find, in
fin-de-siecle Vienna, 39 women and 5 men. Why is that?
The path to Kierling-Gugging

Is the excess of women somehow related to admission procedures to the asylum or
to the selection of patients? This seems the least likely of possible explanations.
The Kierling-Gugging asylum, established in 1885 in the buildings of a private
sanatorium, originally was a branch (Filiale) of the main Vienna asylum, or
Landes-Irren-Anstalt Wien. It became independent in 1890, with the right to
admit patients directly. But even after 1890 many of the patients would come as
overflow from other institutions rather than as fresh cases, admitted directly at the
say-so of a county medical officer.
There actually were four ways to get into the asylum at Kierling-Gugging.
(1) As transfers from the main provincial asylum in Vienna. Chronically over-
filled, the main Vienna asylum was avid to slough patients to outlying institutions.
But of the 44 patients in this study who ended up at Kierling-Gugging, only 10
came as transfers from the main Vienna asylum (6 with manic-depression and two
each with hysteria and mania). Nor were these ten necessarily chronic patients,
regarded as hopeless, for the longest time any of them had previously spent in the
Vienna asylum was 6 months, and two had been there only several weeks before
being transferred to Kierling-Gugging.
(2) As transfers from the psychiatric clinic of Vienna’s General Hospital,
technically known as the ’second psychiatric clinic’ but called in medical parlance
the observation room, Beobachtungs-Zimmer, or simply, die Beobachtung. Into
these desperately cramped, shabby quarters flowed most of the city’s emergency
psychiatric admissions. The clinic staff moved them out as soon as beds opened
elsewhere, so that the average stay was only a few days. Of the 44 patients in this
study, half had come as referrals from this psychiatric clinic, and most of them

6
were long-time residents of Vienna, not residents elsewhere of the province of
Lower Austria (Niederosterreich, the name of the province that included Vienna).
From the clinic’s founding in 1875 until 1892, Theodor Meynert was its chief
physician, from 1892 to 1902 Richard von Krafft-Ebing, and from 1902 to 1928
Julius Wagner-Jauregg. As these are three of the biggest names in the history of
psychiatry in Central Europe, one realizes that diagnosis at this clinic was not
taken lightly.
(3) Of the forty-four, 5 came as referrals from hospitals in small towns in Lower
Austria, such as Krems an der Donau. They had become psychotic as medical
patients, and the general hospitals, unable to control them, moved them on to the
asylum.
(4) As direct admissions, referred to Kierling-Gugging mainly by district medi-
cal officers of health (Bezirksdrzte) outside of Vienna. (The police doctors
[Polizeidrzte] in Vienna, referred patients to the main Vienna asylum and to the
General Hospital’s psychiatric clinic.) Typically the family, or neighbours would
bring the patient to the court or police commissariat, where the officer of health
would conduct a mental status examination and then send the patient on, under
supervision and accompanied by a commital note (Parere), to Kierling-Gugging.
Five of the 44 come in this category.
Thus, although Kierling-Gugging did indeed house great numbers of chronic
patients, the 44 in this study had virtually all been sick only a few weeks or months
before they entered the asylum. I refer, of course, only to the ’current episode’, or
’presenting illness’. Many of them had long previous psychiatric histories.
Does the female surplus of mania and hysteria occur because doctors diagnosed
the same symptoms which they called ’mania’ in women as something else in men?
Probably not in the case of ’hysteria’, because the fits and ’Charcot-style’ signs and
symptoms used for the diagnosis were quite distinctive. Had men presented
them, they would have received the diagnosis too, especially on the part of doctors
under the influence of Jean-Martin Charcot (as these Viennese doctors were), a
5
man who styled himself as the discoverer of male hysteria
It is more difficult to say, however, if mania was more often overlooked in men
than in women because, in the absence of medical records for males with ’mania’
written on their cover, one would have to know which of the hundreds of other
male charts labelled as ’paranoia’ or ’primary insanity’ (primäre Verrücktheit) were
5
See Jan Goldstein, Console and Classify: The French Psychiatric Profession in the Nineteenth Century
(New York: Cambridge U.P., 1987), 322-377. It might be argued that the Viennese medical community,
supposedly sceptical of Freud’s presentation on ’male hysteria’ in 1895, would be generally inclined to
misdiagnose hysterical symptoms in men. In fact: (1) Many of the members of the ’Wiener medizinisches
Doctoren-Collegium’ who attended Freud’s talks were not dubious of the existence of male hysteria, only
of Freud’s explanations of hysteria in general. Various comments from the floor to this effect were
reported in the Wiener Medizinische Presse, xxxvi (10 November, 1895), cols 1717-18, and 17 November,
cols 1757-58. (2) Many Viennese doctors did diagnose hysteria in males. At Wilhelm Svetlin’s private
nervous clinic in Vienna’s III district, for example, 5 males received the diagnosis in the period 1879-91,
4 females. See Shorter, ’Women and Jews in a private nervous clinic in late nineteenth-century Vienna’,
Medical History,
xxxiii (1989), 149-183, esp. p. 174.

7
in fact cases of male mania that had been misdiagnosed. I have not been able to do
this analysis for the present paper.
How else might women be diagnostically disadvantaged? The symptoms of
mania often appear in the early stages of other disorders, such as schizophrenia or
neurosyphilis. And doctors careless of making an exact diagnosis in female
patients might suspect ’mania’ more often in women than in men, thus missing
the real, underlying disease process. Yet in the Kierling-Gugging charts there is
no suggestion that the medical staff were diagnostically more cursory for women
than for men, or that the female ’mania’ patients had some other ’underlying’
disorder. The detail preserved in the charts of both sexes is, in fact, astonishing
and typifies the meticulousness of the ’descriptive’ psychiatry of the day.
Does the female surplus occur because women were more likely than men to be
funnelled into an asylum? Might women have more often been defined as ’insane’,
or ’dangerous to the public order or to oneself’ (gemeingefährlich or selbstgefdhrlich)
by the district medical officer, or by the families who sought out the officer? Did
men with similar symptoms end up in jail?6 These are difficult questions. Consider
Helene G., 27, admitted in 1897 to the main Vienna asylum. She had been living
at her father’s home in Vienna’s XIXth district, a nice part of town, when early in
September of that year she started to get ’frequent attacks of palpitations with
feelings of anxiety and noisy fits of crying. She hallucinates various odours, which
cause her to change her underwear several times a day and use a lot of perfume.
She expresses anxiety about being alone, saw once the angel of death in a hallucina-
tion, and feels she is about to die; she has to be forced to eat, and voices suicidal
thoughts’. But when her family, accompanied by family doctor Wenzel Schiller,
took her to see the XIXth district’s medical officer of health, Dr Philipp Silberstern,
at the local police station, she was chatty and in an inappropriately cheerful mood.
She told Dr Silberstern about her ’excitability’ (Erregbarkeit). ’She feels terror in
looking at familiar pieces of decoration, such as the mirror, and cries out on
innocuous occasions, as for example when at night in her room she hears an acorn fall
from the tree’. She also has had for years a history of loss of appetite, lower-back pain
and headache. Three years ago she had a ’mental disturbance (melancholy).’
Thus Fraulein G’s symptoms did not pose an immediate danger to herself or
those around her. She was obviously having a recurrence of her past depression, in
an agitated form, with the kinds of aches and pains that often accompany depres-
sion. She was clearly disturbed, indeed melancholic, but not floridly psychotic. It
is most unlikely that such a patient today would be locked up against her will, and
would instead probably receive antidepressant medication and psychotherapy
(which she might have been in need of because two years later she became
6
Harold Merskey notes, ’In our conventional notions of males, psychosis typically leads to disruptive
behavior in which they cannot be controlled. With a crowded asylum in Vienna, obstreperous male
psychotics might well have finished up in jail. Our idea of psychosis in women, by contrast, often looks not
just at those features which men show, but also at sexual disinhibition. If a woman who is normally
restrained and modest throws off her clothes, surely that does require psychiatric attention.’ Personal
communication.

8
engaged, broke the engagement off and in 1901 bore an illegitimate child). Instead
Dr Silberstern committed her involuntarily to the main Vienna asylum as ’dangerous
7
to others’ (gemeingefa’hrlich).~
I have seen no charts of male patients admitted to Kierling-Gugging for such
lesser symptoms. The men tended to have severe psychiatric and neurological
illnesses. Of course Helene G. was a city woman, and was sent in this illness to a
city asylum (the records of which have been destroyed) rather than to a rural
asylum in a catchment basin for peasants. So it is possible that male Viennese also
ended up in the main Vienna asylum for minor depression. But I doubt it. Among
these 44 patients are many like Helene G., at first not so severely ill but with
personality disorders or lesser depressions. By contrast, all 5 men among the 44
were frankly psychotic at the time of their first admission to an asylum, meaning
they had hallucinations, delusions or illusions.g The initial recruitment process, at
the level of police doctor and county medical officer, was probably more sensitive
to aberrant behaviour of any kind in women.
But even if the system was more sensitive to psychiatric illness in women, it must
not be forgotten that a majority of patients in Lower Austria’s public asylums were
men, because the major illnesses of the day - especially alcoholism and neurosyphilis
-
were commoner in men than women. Kierling-Gugging admitted in 1905, for
example, 224 men and 186 women; Vienna’s main asylum 925 men and 703 women,
and so forth.9 The ’plastic’ disorders that are the subject of this paper represented
only a fragment of all asylum admissions. At Kierling-Gugging in 1900, ninety
patients were admitted for ’paranoia’, sixty for alcoholism, thirty-eight for general
paralysis of the insane (paralytische Geistesst6rung - a form of neurosyphilis), a
majority of the above being men. By contrast six were admitted for hysteria or
hysterical insanity. They were women of course. 10
Hysteria
Hysteria offers a classic example of patients who present symptoms as the culture
7
Landes-Irren-Anstalt Kierling-Gugging (hereafter LIAKG) 1904/23. Her diagnosis on admission to
the main Vienna asylum (Landes-Irren-Anstalt Wien) was ’neurasthenic mental disturbance (circular
insanity?)’. Cases will be cited according to the order of discharge from Kierling-Gugging in any particular
year; in this case Helen G. was number 23 to be discharged in the year 1904. The patients’ ’charts’ are
stored in the attic of LIAKG today in this order. In Helene G.’s 1897 illness episode, she would spend
eight months in the Landes-Irren-Anstalt Wien (LIAW) and remain well until further bouts of illness
brought her to LIAKG, which asylum made copies of her earlier charts.
8
The five are: Eduard N., 25, mania, LIAKG 1891/85; Josef D., 37, periodic mania, 1892/122;
Ferdinand D., 14, mania, 1893/29; Johann K., 45, mania periodica, 1901/183; and Karl. P., 46, circular
insanity,
9
1897/28. Age and diagnosis at time of admission to LIAKG.
A convenient overview of Central Europe’s public and private asylums around 1905, naming the
members of their medical staffs and giving numbers of admissions and discharges is offered in Hans
Laehr, Die Anstalten für Psychisch-Kranke, 6th ed. (Berlin, 1907). These data from pp. 105, 223.
10
At LIAKG admissions and discharges were tabulated in a separate register, kept now in the director’s
office.

9
expects them, or better put, as the doctors expect them. &dquo; The doctors have a
definition of what counts as ’hysterical’. The patients produce the symptoms and
then qualify for the diagnosis. What did the Viennese psychiatrists understand by
’hysteria’ around 1900? They had three main traditions to draw upon.
The oldest tradition in the medical diagnosis of hysteria defines the disease
basically as convulsive phenomena, or fits. Going back to the ancient Greeks and
Romans, patients have long produced pseudo-epileptic fits and doctors have
termed these fits ’hysterical’, initially meaning originating from the womb
What did such hysterical fits look like among young Viennese women? Maria S.,
34 at the time of her admission to the city’s psychiatric clinic in 1900, had
quarrelled with her husband a few days previously. ’She became so excited
[aufgeregt] that she could not sleep at all that night. As she lay sleepless in bed, she
had a feeling as though her legs were growing stiff. This stiff feeling then
gradually went over to her rump and her arms, and as it was about to pass into her
head she sprang horrified out of bed.’13 This episode helped give her the diagnosis
of ’hysteria’ at the psychiatric clinic, and was called a ’hysterical fit’ (hysterischer
Anfal~ as she was transferred four weeks later to Kierling-Gugging. Henriette
G.’s fit in 1901, ’threw her like a ball into the air’; she lost consciousness. 14 The fits
of Karoline P., 26, began in 1901 the day she learned her husband had raped her
younger sister. Over the next two years the husband produced an illegitimate
child by another woman and Karoline’s fits worsened. Her husband beat her
during these fits. Then in August, 1903, the mother of the husband’s girlfriend
appeared in Karoline’s dwelling and beat Karoline for having insulted her daughter.
The husband, who was present, also beat Karoline. Karoline then moved out, and
when the husband refused to pay the promised support, Karoline approached him
at his place of work and tried to kill him with a knife. Having originally wounded
him, she was prevented from chasing after him only because she had a hysterical
fit on the spot. As she fell to the ground she cried out, ’My children! My children!’
(Meine Kinder! Meine Kinder!) One witness described the fits as so powerful that it
took three men to hold her. When psychiatrists Adolf Elzholz and Hermann
Hoevel later interviewed her at the psychiatric clinic about these events she had a
fit in front of them: ’She begins to groan and to swallow convulsively ... waves
her hands around, shakes her head back and forth from left to right. Then both
hands begin to quivver; she sticks out her arms and, holding them rigidly before
11
Hysteria is the classic illustration of Karl Birnbaum’s dictum that organic disease takes on forms
dictated by Nature, neurosis takes on forms dictated by society. ’Während sont bei Krankheiten die
reinen Natur
formen vorherrschen, die besonderen Sozial formen ... die Ausnahme sind, sind umgekehrt
bei den Neurosen die Sozial- und Kulturformen fast die Regel, wahrend die reinen Naturformen mehr
zurucktreten.’ Soziologie der Neurosen: Die nervosen Storungen in ihren Beziehungen zum Gemeinschafts-und
Kulturleben (Berlin, 1933), 6.
12
The standard history of epilepsy and pseudo-epilepsy is Owsei Temkin’s The Falling Sickness: A
History of Epilepsy from the Greeks to the Beginnings of Modern Neurology, rev. ed. (Baltimore: Johns
Hopkins, 1971), see pp. 351-359.
13
LIAKG, 1900/197.
14
LIAKG, 1902/279.

10
her, beats the air around.’ After a while the arms relaxed and she started moaning,
’My head! My heart! My poor children! 15
It is thus evident that two parties were required to make the diagnosis of ’hysterical
fits’, the patients who produced the fits for the benefit of the surrounding community
and the medical staff, and the doctors who diagnosed them as ’hysterical’. Of the 10
women who received the diagnosis of ’hysteria’ or ’hysterical insanity’, 8 had fits of
some kind. (Some of the 8 also had other hallmarks of ’hysteria’.)
’Charcot-style’ hysteria represented a second tradition in diagnosing the disease
upon which Viennese doctors drew. Of all concepts of hysteria, that envisaged by
Charcot comes closest to being pure artifact, symptoms which patients would
otherwise never produce unless suggested into them medically or by reading
magazine articles about the disease. Charcot, the master of the Salpetriere hospital
in Paris from the early 1860s to early 1890s, drew up an elaborate set of ’laws of
hysteria’, in which more or less permanent ’hysterical stigmata’ would alternate
with brief but dramatic attacks of ’grande hysterie’. The stigmata included such
phenomena as the loss of feeling on one clearly-demarcated side of the body
(hysterical hemianaesthesia), the feeling of a lump in the throat (globus hys-
tericus), or the contraction of the visual fields. Most diagnostic of the stigmata
was, in Charcot’s view, ’ovarie’, which meant the ability of the physician to
unleash or stop a hysterical fit by pressing upon ’the ovaries’ through the anterior
abdominal wall. Many physicians never succeeded in actually starting and stop-
ping attacks through this mechanism, but if lower abdominal palpation produced
a feeling of discomfort, they would pronounce ’ovarie’. As for la grande hysterie,
each attack would theoretically evolve through four phases, the first two involving
histrionic convulsions, the latter two emphasizing delusions and hallucinations. 16
Of course, nothing like the complete sequence of stigmata and grande hyst6rie
was ever seen in Vienna (nor anywhere else outside the hospitals of Charcot’s
students), but Charcot’s doctrines disseminated widely in Central Europe, and

much Charcot-style hysteria was noted there. 17 It was probably Max Leidesdorf,
15
16
LIAKG, 1904/156.
Although Charcot himself never produced a textbook codifying his doctrines, his students wrote
various glosses of his baroque system. See, for example, Paul Richer, Études cliniques sur la grande hystérie
ou hystéro-épilepsie, 2nd ed. (Paris, 1885). Most of the ’stigmata’ of hysteria had
previously been linked to
the disease by other doctors. But Charcot pulled all these together in a grand system. On ’ovarie’, for
example, see Raoul LeRoy d’Étiolles, who found in some patients with hysterical paralysis, local pain
’dans un point correspondant à l’ovaire’. Des paralysies des membres inférieures ou paraplégies, 2 vols (Paris,
1856-57), vol. 1, 206.
17
See for example Adolph Strumpell’s indignant comment upon a review of the German translation of
Charcot’s lectures. The reviewer ([Leopold?] Laquer) had maintained that hysteria as seen at the
Salpêtrière was still ’sonderbar und unerklarlich’ for German physicians. Neurologisches Centralblatt, vi
(1887), 429-432. Strumpell responded that, to the contrary,"die grosse Hysterie," ganz wie sie Charcot
uns kennengelernt hat, [ist] in Deutschland gar keine Seltenheit, worin mir gewiss jeder erfahrene
Nervenarzt ohne Weiteres beistimmen wird.’ ibid., 487-488. In 1887 a case of Charcot-style hysteria was
described in Munich. Heinzelmann, ’Ein Fall von Charcot-scher Hysterie’, Münchener medicinische

,
11
professor of psychiatry in Vienna until 1889 and co-owner of an expensive private
nervous clinic, who imported (or ratified) Charcot’s doctrines for the Viennese
psychiatrists. In 1879 Charcot cited Leidesdorf as confirming the universality of

‘ovarie’.1g In any event, by the 1890s the Viennese doctors were checking alertly
for symptoms of Charcot-style stigmata and
trying1 to determine whether patients’
seizures could be qualified as la grande hystérie.l
Thus patients in Vienna in whom hysteria was suspected would routinely be
examined physically for the stigmata. Doctors at the psychiatric clinic, for
example, succeeded in touching off a fit all of her limbs went rigid - by pressing
-
upon Marie S.’s lower abdomen. Krafft-Ebing signed this particular note.2
Caroline W., a nineteen-year-old Viennese woman, offered a virtual blizzard of
stigmata as she came into the psychiatric clinic: a right-sided ovarie, globus
Wochenschrift, xxxiv (July 26, 1887), 571-572. In 1912 Armin Steyerthal wrote of Charcot’s enormous
influence on German notions of hysteria. Steyerthal summarized Charcot’s doctrine: ’Hysterische ist, wer
ein Stigma tragt, und sonst niemand.’ ’Hysterie und Praxis,’Medizinische Klinik, viii (1912), 1267-70,
quote from p. 1267.
18
Charcot’s ’Description de la grande attaque hystérique’ (summary by Paul Richer), Le Progrès
médical, vii (11 Jan, 1879), 17-20; Charcot alludes on p. 18 to Leidesdorf’s findings. Yet Charcot also had
other connections to Vienna, writing, for example, the preface to the French translation of electrotherapist
Moriz Rosenthal’s Klinik der Nervenkrankheiten (2nd ed., Stuttgart, 1875; Traité clinique des maladies du
système nerveux, trans. from 2nd German ed. [Paris, 1878]). Yert Rosenthal, with his belief in such
derivations of ’reflex theory’ as cauterizing the clitoris for hysterical vomiting, did not have as much
influence as Leidesdorf among the ’brain’ psychiatrists of the 1880s and -90s, who saw hysteria as a
weakness of the central nervous system rather than a result of ’peripheral irritation’. For Rosenthal’s
advocacy of clitoridectomy see his Zur Diagnose und Therapie der Magenkrankheiten, insbesondere der
Neurosen des Magens (Vienna, 1883), 20.
19
One academic psychiatrist who imported Charcot’s doctrine to Vienna was Wagner-Jauregg’s favourite
pupil Emil Raimann, from 1899 to 1913 an assistant physician at the psychiatric clinic. See Raimann’s
massive work, Die hysterischen Geistesstorungen: eine klinische Studie (Leipzig, 1904). Raimann considered
’ovarie’ and the presence of other ’hysterogenic’ points on the body to be absolutely diagnostic of
’hysteria’. (See for example p. 336.) On Raimann as Wagner-Jauregg’s ’favourite pupil’, see the manuscript
of Erwin Stransky’s highly revealing autobiography in the Institut für Geschichte der Medizin in Vienna,
p. 234 and passim.
Wagner-Jauregg himself never wrote widely on the subject of hysteria, yet was a firm believer in
Charcot’s theories. In his own manuscript autobiography he scorned Theodor Meynert and Alfred Fuchs
(an assistant physician at the psychiatric clinic, first under Krafft-Ebing and then under Wagner-Jauregg
himself) for their scepticism of Charcot. Wagner-Jauregg presented at rounds one day a male patient who
had had something fall on his head ’and from then on was blind in one eye, aphonic [mute], and anaesthetic
on one side’. Fuchs and Meynert insisted that the deficits must be organic. ’But I already knew quite a bit
of the teachings of Charcot about hysteria’, recalled Wagner-Jauregg, ’and presented the patient in my
[neuropathology] course as hysteria, which naturally was ridiculed by Meynert and Fuchs.’ One day,
however, the patient became angry at a co-patient and started cursing him, ending the aphonia, whereupon
the other symptoms fell away too. Fuchs told Meynert that Wagner-Jauregg was right after all. Manuscript
in possession of the Institut fur Geschichte der Medizin in Vienna. A highly edited and cleansed version of
Wagner-Jauregg’s rather pungent original was published. L. Schonbauer & M. Jantsch, eds., Julius
Wagner-Jauregg:
20
Lebensennnerungen (Vienna: Springer, 1950).
LIAKG, 1900/197. The chart of her admission to the II Psychiatrische Klinik (16 April-14 May
1900), on which Krafft-Ebing’s signature appears, accompanied her to Kierling-Gugging. ’Nabel
hysterogene Zone. Bei Druck ... Hinfallen des gestreckten Körpers ohne Bewusstseinsverlust.’

12
hystericus, a right-sided hysterical headache and a bilateral contraction of her

visual fields. She also claimed a history of such symptoms as ’total body anaes-
thesia’, and a variety of Charcot-esque fit called ’arc de cercle’ (opisthotonos), in
which the patient lies rigid in hyper-extension, only the back of the head and the
heels touching the ground. She also had experienced fits of grande hyst6rie in
which she would lash out angrily about herself.21 In another case, Wagner-Jauregg
could elicit only pain on pressure (Druckschmerz) all over Marie W.’s body, plus a
hyperaesthesia (skin feels all funny) on the left side, but this nonetheless qualified
her for ’hysteria’. 22 Because Wagner-Jauregg had found a left-sided ovarie and
slight hyperaesthesia in Josephine S., 23, her diagnosis was changed from ’de-
generative insanity’ (degeneratives Irresein) to ’hysteria’ when she was transferred
in June, 1903, from Wagner’s clinic to Kierling-Gugging.23
Charcot-style features were found in 7 of the 10 hysteria patients. One recalls
that these symptoms were not merely figments of the doctors’ minds: they were
found in patients in clinical examinations, a result of suggestion the patients had
received from someplace, from other medical settings or from the larger culture.24
Thus even though it was Charcot who ultimately had invented the disease, it took
on a reality in the lives of patients before they ever came into contacf with doctors.
A final medical tradition in the diagnosis of hysteria concerned personality
changes, the so-called ’hysterical character’ or ’hysterical personality’. It implied
a special kind of impressionability, in combination with lability of mood. In actual
fact, hysterical character was not often invoked in the diagnosis of ’hysteria’
because the same personality qualities played an even more important role in
mania and manic-depressive illness. Yet such nebulous about speculations
of
’hysterical’ aspects personality were then sweeping theoretical medicine in
Europe, and surfaced as well in the charts of several of these Viennese patients.
Thus Franziska S., a married woman of 30 who had suddenly bolted from home
to run away to Munich with the son of the concierge of her building, was
considered possibly ’hysterical’ for the first time after she reported a sensation of
’globus’. But it was the personal impression she made upon the Kierling-Gugging
21
22
LIAKG, 1901/81.
LIAKG 1903/201.
23
LIAKG, 1904/134. It is, however, of interest that some doctors checked impartially for the stigmata
in male patients as well. Finding them, however, was apparently not enough to shift the diagnosis to
hysteria if other psychotic symptoms figured prominently in the case. Thus for example Eduard N.,
admitted directly to LIAKG in 1901, was still diagnosed with ’mania’, even though he demonstrated a
left-sided ovarie. LIAKG 1891/85. ’
24
It is interesting that two of the LIAKG’s hysteria patients had themselves earlier worked as orderlies
in private psychiatric clinics, Josefine S. (LIAKG 1904/134), who had been a Wärterin at Heinrich
Obersteiner’s clinic in Ober-Döbling, later part of Vienna’s XIXth district, and Katharina D., whom I
have not included among the 10 hysteria patients because she died in 1897 in LIAKG of what was
apparently an underlying neurological disease. Yet earlier she had evidenced ’hysterical’ symptoms that
could have been a psychogenic overlay upon her organic disease. In any event, she had worked in 1879-80
as an attendant in Wilhelm Svetlin’s private psychiatric clinic in the III district.

13
doctors in 1895 that led to the full-blown diagnosis of ’hysterical insanity’, for they
thought her ’easily influenced [leicht bestimmbar], impressionable, subject to
exaltations and to strong emotions [Affekte].’25
Marie W.’s attacks of fits, which seemed to pull her over backwards, would
have qualified her for ’hysteria’ in any event, but the Kierling-Gugging doctors
noted ’hysterical character’ on the cover sheet of her chart because, in her initial
interview, she had ’told the story of her illness in great detail, and emphasized all
the points that called attention to the multiplicity and gravity of her sufferings.
Spontaneously she tells of the burden of her heredity [hereditäre Belastung -
evidently her ’irresponsible, spendthrift’ father], and glories in the use of technical
medical terms, ever ready with suggestions about the programme of treatment to
be followed.’26 Thus deemed self-centered, histrionic and demanding, Marie W.
was an unpleasant patient whom they put at arm’s length by labelling her personal-
ity ’hysterical’. Such attributes of personality seem to have contributed to the
diagnosis of hysteria in three of the ten patients.
The Viennese doctors might be said to have had a tacit system for weighting
symptoms in the diagnosis of hysteria similar to the system for weighting
symptoms in the diagnosis of schizophrenia today (for example, ’first-rank’
symptoms in schizophrenia, paramount in making the diagnosis, call for the
presence of such phenomena as thought-insertion or thought-broadcasting). 27
The most powerful first-rank symptoms of hysteria were clearly fits, seen in 8 of
the 10 patients; then came Charcot-style phenomena in 7 of the 10, followed by
’lability’ of the personality and so forth in three. Few statistics could make clearer
the culturally-determined nature of hysterical symptomatology, for within years
after these patients had through Kierling-Gugging the entire Charcot
passed
edifice would lie in ruins.And convulsive hysteria would be on its way out, to
give way to psychogenic sensory symptoms.29
25
LIAKG, 1896/16. The globus was noted during her stay in 1894-95 in the provincial asylum at Ybbs,
where her official diagnosis remained, however, ’Amentia’. Her diagnosis had become full-blown ’hys-
terische Geistesstorung’ by the time of her admission to LIAKG in 1895.
26
27
LIAKG, 1900/197.
For an overview of different national traditions today in determining such ’first-rank’, or ’Schneiderian’,
symptoms, see Peter Berner,
et al., ’DSM-III in German-Speaking Countries’, in Robert L. Spitzer, et al.,
eds, International Perspectives on DSM-III (Washington: American Psychiatric Press, 1983), 109-125.
’DSM-III’ means the third edition of the Diagnostic and Statistical Manual of the American psychiatric
profession,
28
published in 1980.
Semi Meyer suggested that by 1910 many German physicians had already ceased checking for ’ovarie’,
in order to avoid suggesting patients into symptoms. ’Die Diagnose der Hysterie’, Medizinische Klinik, vi
(1329 Feb, 1910), 259-261.
It is noteworthy that among 120 patients with organic symptoms of a psychogenic nature seen in 1986
and 1987 in a clinic for psychosomatic medicine in Toronto, only one had a chief complaint which
resembled at all the classical ’motor’ fits, a women with ’drop-attacks’, in which she would suddenly fall to
the floor, apparently unconscious. The other patients presented mainly sensory disturbances and pain.
Unpublished research by Z. J. Lipowski, S. Abbey & E. Shorter.

14
What was actually the matter with these ’hysteria’ Did they suffer at patients?
all from psychiatric disease, or were they merely rebelling against ’confining role
models’ in an inarticulate, personal way ?30 Of the ten, 5 had some kind of a major
mental disorder.31 At this distance it is impossible to say exactly what it was, but
these 5 patients were at some point clearly psychotic. Katharina H., 36, single,
and from a village in Lower Austria, was admitted directly to Kierling-Gugging in
1904. She had recently learned of a lover’s faithlessness, had thereupon miscarried
a pregnancy of two months’ duration, and then started to hear bells ringing at
night, ’as though she were receiving the last rites’. On the basis of her belief in her
deep wickedness, her sadness, and her multiple somatic complaints, one might
have said she was depressed. Her sensation of globus, however, won her a
diagnosis of ’hysterical insanity with neurasthenia [because of her many physical
complaints]’ (Hysterische Geistesstörung. Neurasthenie). At admission she was
anxious, spoke rapidly, moved about restlessly, could not get off the subject of her
anxiety, and kept losing the theme of the conversation. Once admitted she got into
a pattern of beating up some female patients, kissing and embracing others. When
her brother visited, ’she shows her private parts to him, spreads her legs apart,
calls out shameful expressions to him, and insists that he have coitus with her.’32
There was much more. She might, for example, stand for hours in the same
posture ’as though cast in metal, therefore often getting pedal [foot] edema’. One
30
Elaine Showalter asks, ’Was hysteria ... a mode of protest for women deprived of other social or
intellectual outlets or expressive options?’ After considering several Viennese hysterics in Freud’s and
Breuer’s writings, she answers, basically, yes: ’Hysteria and feminism do exist on a kind of con-
tinuum.... The availability of a women’s movement in which the’"protofeminism" of hysterical
protest could be articulated and put to work, offered a potent alternative to the self-destructive and
self-enclosed strategies of hysteria, and a genuine form of resistance to the patriarchal order.’ The Female
Malady: Women, Madness, and English Culture, 1830-1980 (New York: Pantheon, 1985), 147, 161. There
are some problems in applying this argument to the ten lower-class hysteria patients in Kierling-Gugging.
31
The cases were: Franziska S., LIAKG 1896/16; Marie S., 1900/197; Caroline W., 1901/81; Marie W.,
1903/201; and Katharina W., 1903/246.
Some readers may wish to see ’hysterical psychosis’ or ’hysterical insanity’ as a tradition sui genens in the
historical development of the diagnosis of hysteria. Whatever theoretical significance the writers of the
time assigned to this purportedly distinctive form of psychosis, in practice ’hysterical insanity’ seems to
have meant mainly ’hysteria-plus-psychosis’. An entry point into the enormous body of contemporary
writing is Paul Bercherie, ’Le Concept de la folie hystérique avant Charcot’, Revue internationale d’histoire
de psychiatrie, i (1983), 47-58. I am indebted to Mark Micale for this reference. Étienne Trillat also offers
a brief history of the concept in France in Histoire de l’hystérie (Paris: Seghers, 1986), 261-263. For two
compact contemporary overviews of the subject see Julius Raecke, ’Hysterisches Irresein’, Berliner
klinische Wochenschrift, xlvi (11 March, 1907), 265-269, and Otto Binswanger, ’Uber die forensische
Bedeutung der hysterischen Psychosen’, Jahreskurse für arztliche Fortbildung, v (1913), 64-73. Medical
opinion today in the United States is disinclined to qualify any psychotic illness as ’hysterical’, yet in some
circles the notion lingers on. For a brief survey see Harold Merskey, The Analysis of Hysteria (London:
Ballière Tindall, 1979), 210-211.
32
LIAKG, 1905/171. She was discharged six months later ’gegen Revers’, to her brother-in-law,
meaning under his supervision.

15
might imagine that Katharina H. had schizophrenia.33 In any event, she had a
substantial mental disorder. So did four other patients in this group of 10, for
whom the term ’hysteria’ merely confused the real diagnosis. But the major value
judgements of these middle-class medical males about women came not in the
domain of hysteria but in that of mania. 14
Mania
Mania, like paranoia or major depression, is a familiar, recurrent psychiatric
affliction and has been known since the ancient Greeks.35 It is distinguished by its
core ’triad’ of symptoms: manic mood, pressure, speech or ’flight of ideas’, and
hyperactivity.36 It goes without saying that judgement of these qualities is culturally-

bound. The German psychiatrist Hans Bfrger-Prinz remembered, in a visit to a
Parisian psychiatric clinic, being asked by the staff to assess and diagnose a
’patient’. ’From a purely diagnostic point of view, the case was a simple one. The
way the fellow behaved was extremely striking: a kind of disaffiliation [Entdus-
serung], a richness in his gesticulation, a torrent of speech that buffeted me like
33
The diagnosis ’hysterical insanity’ or ’hysterical psychosis’ was often confused with schizophrenia. As
Eduard Hess wrote in 1902, ’[One] group of psychoses in which, especially at the beginning of the illness,
the so-called hysterical symptoms are found in plenty is dementia praecox [schizophrenia].’ ’Ueber
hysterisches Irresein’, Psychiatrische-Neurologische Wochenschnft, iv (6 Dec., 1902), 393-397; quote from
p. 395. Ernst Beyer, director of a private nervous clinic, wrote in 1906 that the diagnosis ’hysteria’ often
conceals ’a mania, catatonia or dementia praecox’. He therefore excluded ’difficult cases’ of hysteria from
his facility. ’Zur Eroffnung von Roderbirken, der ersten Rheinischen Volksheilstatte fur Nervenkranke’,
ibid., viii (26 May, 1906), 79-82, quote from p. 81. On the differential diagnosis of ’hysterical psychosis’
and dementia praecox, see Raimann, op. cit., pp. 285-286. Sigmund Freud learned subsequently that the
famous ’Emmy von N.’, a ’hysteric’ whom he had treated early in his practice, had later ’turned into’ a
schizophrenic. Freud & Breuer, Studien uber Hystene (1895), reprinted in Freud, Gesammelte Werke: vol. 1
1
(Frankfurt: Fischer, 1952), 151, note made in 1924.
4 Disapproving moral judgments of women’s sexual behavior were made in two of the hysteria cases, yet
enough other ’signs’ of hysteria were present so that the diagnosis did not rest alone on the ’sexual excess’
of Franziska S. nor on Marie S’s long history of masturbation.
35
Stanley Jackson considers the history of mania in his book, Melancholia and Depression from Hippocratic
Times to Modern Times (New Haven: Yale U.P., 1986). On the evolution of the ’mania’ diagnosis in France
see P.-L. Couchoud, ’Histoire de la manie jusqu’à Kraepelin’, Revue des sciences psychologiques, i (1913),
149-173. For an incisive introduction to the history of the concept of manic-depressive illness generally,
several articles of G. E. Berrios may be consulted, notably, Berrios, ’ "Depressive Pseudodementia" or
"Melancholic Dementia", a 19th Century View’ ,Journal of Neurology, Neurosurgery, and Psychiatry, xlviii
(1985), 393-400, and Berrios, ’Melancholia and Depression During the 19th Century: A Conceptual
History’,
36
British Journal of Psychiatry, cliii (1988), 298-304.
See, for example, Ludwig Binswanger, a distinguished psychiatrist and owner of a private nervous
clinic in Kreuzlingen, Switzerland, on ’die mamsche Trias’: ’Beschaftigungsdrang, Ideenflucht, gehobene
Stimmung.’ ’Uber die manische Lebensform’, Schweizensche medizinische Wochenschrift, lxxv (20 Jan.,
1945), 49-52, quote from p. 52. A recent, elaborate statistical analysis largely confirms this classic view.
Michael A. Young, et al., ’Establishing Diagnostic Criteria for Mania’, Journal of Nervous and Mental
Disease, clxxi (1983), 676-682. The authors noted, ’Grandiosity and flight of ideas were related to this class
but did not make a significant contribution to it’ (p. 681).

16
machinegun fire; and on top of this a cataract of ideas one after the other. For a
long time I remain glued to my chair in the role of a fascinated spectator.’
So Bfrger-Prinz presented the case to the clinic’s medical staff.
They asked him for his diagnosis. He said later, he should have been warned by
the fact that many of them were choking with scarcely supressed mirth.
’Mania,’ said Burger-Prinz. The room fell about in laughter.
The ’patient’ was just a typical resident of Marseilles, entirely normal, whom
the French doctors had planted on the German visitor. 37
So the ’mania’ may be mainly in the eye of the beholder. Yet within the context
of Central Europe a persistent pattern of mania, constant across time and place,
does hallmark certain psychoses. 38 The problem is that, historically, authors who
described ’mania’ tended to include the symptoms of every other psychosis as
well. The term becomes sharply defined only in the 1870s and 80s with the
writings of Krafft-Ebing, Ludwig Hirn, and of course Emanuel Mendel’s 18811
monograph, Die Manie, which in particular defined ’hypomania’ as a clinically
distinct, non-psychotic form of psychiatric illness.39 (There is a problem of
differentiating organically-determined delirium [Tobsucht] from mania, at a time
when many observers took the two to be synonymous
Even though the Viennese psychiatrists had a clear definition of mania at their
disposal, they doubtlessly committed all these sins: they confused normal person-
ality variants with mania, they diagnosed febrile delirium as mania, and they
probably called ’manic’ some patients with hebephrenic schizophrenia (’hebe-
phrenic’ means silly behaviour, in the context of a psychosis, and especially in
37
38
Hans Burger-Prinz, Ein Psychiater Berichtet (Hamburg: Hoffmann & Campe, 1971), 91-92.
See, for example, Heinrich Hoffmann’s summary of what he considered ’mania’ in Beobachtungen und
Erfahrungen uber Seelenstorungen und Epilepsie in der Irren-Anstalt zu Frankfurt a.M. (Frankfurt a.M.,
1859),57.
39
Richard von Krafft-Ebing, Lehrbuch der Psychiatrie auf klinischer Grundlage (Stuttgart, 1879). I
consulted the 4th ed. (1890), with its delineation of mania on pp. 362-368, and differential diagnosis from
’Wahnsinn’ on p. 400-401. Many of Krafft-Ebing’s phrases reappear in the Viennese case histories, and it
is not unreasonable to assume that in the psychiatric clinic, where he was the Professor of Psychiatry, his
textbook was the standard guide to diagnosis. W. Janzarik comments upon the influence of Krafft-Ebing’s
textbook in modern definitions of melancholy and mania. Janzarik, ’Wandlungen des Schizophreniebeg-
riffes’, Nervenarzt, xlix (1978), 133-139, esp. p. 134. See also Ludwig Kirn, Dir penodischen Psychosen
(Stuttgart, 1878). August Hegar, in his account of Kirn’s life, noted that Kirn ’was the first to describe a
sharply delineated clinical picture of periodic mania, melancholia, and circular psychosis’. Theodor
Kirchhoff, ed., Deutsche Irrenärzte, 2 vols (Berlin, 1921-24), ii, p. 167. J. S. Bolton, in his classic article on
the evolution of the notion of manic-depressive illness, remarks upon the importance of Kirn’s work.
Bolton, ’Maniacal-Depressive Insanity’, Brain, xxxi (1908), 301-318, esp. p. 304. Emanuel Mendel, the
owner of a private nervous clinic in the Berlin district of Pankow, described hypomania in Die Manie: eine
Monographie
40
(Vienna, 1881), 36-54.
See Michael Schmidt-Degenhard, Melanchohe und Depression: Zur Problemgeschichte der depressiven
Erkrankungen seit Beginn des 19. Jahrhunderts (Stuttgart: Kohlhammer, 1983), 73. Delirium today is
defined as an organically-caused state of extreme distractibility and disorientation; manic patients are
usually not disoriented. Mendel said that in delirium (Tobsucht) the patient was febrile and in mania not.
Op. cit., pp. 176-178. It simplifies things that the diagnosis ’Tobsucht’was not used at Kierling-Gugging.

_._--_._--~ ----------- ---.- ---.---&dquo;..... 17
young people) .41 Yet in at least 14 of the 19 cases diagnosed in Kierling-Gugging

as mania, the core symptoms of the disorder seem to be present.
Here is a typical case of mania. After a dispute with neighbours over property,
Josefa R., a farmwife of 43 who lived near the small town of Krems, started
talking very quickly and jumping from subject to subject. She was admitted to the
local hospital in August, 1890, where she was said to be ’restless at night, friendly
in a good-natured way, coy [artig], coquettish, and sexually excited. She speaks in
a constant shower of words [Wortschwall] . There is a histrionic note of &dquo;marvellous-
ness&dquo;. [Der Ton ist pathetisch &dquo;wundervoll&dquo;. ]’
A month later the Krems hospital transferred her to Kierling-Gugging. On
arrival she was continuously of cheery, boisterous spirits, with even greater
hyperactivity; she sang and carried on (’heitere Stimmung und Ausgelassenheit,
grosser Bewegungsdrang ...
singt, jauchzt’), and kept this up day and night.
Although relatively well ’oriented’ (meaning the patient knows where he or she is,
the year, the month, and so on), she was difficult to examine because she darted
from subject to subject. She also ’presses herself up against the doctors and tries to
embrance and kiss them, and leaps over tables and chairs’ .
When the court commission (gerichtsdrztliche Kommission) interviewed her later
in her stay, she demonstrated ’a kind of busy restlessness in plucking at her
clothes, attempted to undress, manifested great flights of ideas, was very chatty
[schwdtzend],’ and was hard to keep on topic. She also showed herself to be
’indifferent towards morally conventional behaviour.’ This was a farmwife who
for 43 years had led an unremarkable life (except for giving birth to twins out of
wedlock at age 27). At the time of her discharge in 1891 she had returned to her old
self, demonstrating insight into her behaviour of the last year as mental illness.42
41
In one collaborative study, American psychiatrists assigned the diagnosis of manic-depressive illness,
manic phase, to only 2 of the 28 patients whom British doctors had diagnosed as manic! Clearly even today
criteria of what constitutes mania are uncertain in their application. This research is cited in Henry B. M.
Murphy, Comparative Psychiatry: the International and Intercultural Distribution of Mental Illness (Berlin:
Springer, 1982), 130. Some of the ’manic’ patients at Kierling-Gugging may later have developed
schizophrenia, a disease that often commences in the form of manic or depressive symptoms. See, for
example, the Swedish data on first admissions for manic-depressive illness in the years 1912-31, in which
’9 out of the 103 patients [9 percent] who at the first onset had been diagnosed as manics were subsequently
found to be schizophrenics’. Gunnar Lundquist, Prognosis and Course in Manic-Depressive Psychoses: A
follow-up Study of 319 First Admissions (Copenhagen: Munksgaard, 1945), 80. On separating mania from
schizophrenia today, see Michael Alan Taylor and Richard Abrams, ’The Phenomenology of Mania: A
New Look at Some Old Patients’, Archives of General Psychiatry, xxix (1973), 520-522. After a review of
symptoms the authors conclude that the diagnosis of a given patient still might be mania even though, on
first glance, his or her symptoms sound like schizophrenia. These authors later argued that it was
diagnostically unimportant whether patients who satisfy the criteria for mania also showed symptoms of
schizophrenia. ’The Importance of Schizophrenic Symptoms in the Diagnosis of Mania’, American
Journal of Psychiatry, cxxxviii (1981), 658-661. See also Gabrielle A. Carlson & Frederick K. Goodwin,
’The Stages of Mania: A Longitudinal Analysis of the Manic Episode’, Archives of General Psychiatry,
xxviii (1973), 221-228, who argue that manic patients may well manifest some schizoid symptoms in the
course of the episide without having schizophrenia. By contrast Ian F. Brocking and collaborators suggest
that there may be two kinds of ’mania’, the one bona fide, the other a variant form of schizophrenia.
’Definitions of Mania: Concordance and Prediction of Outcome’, American Journal of Psychiatry, cxl
(1983),435-439.
42
LIAKG 1891/22.

18
Although an unmistakable moralizing note about sexuality trails through Josefa

R’s chart, she was not merely a female victim of male psychiatric highmindedness.
She had a major mental illness. For half a year her mood and behaviour had
changed significantly, causing problems for those around her. Mania was intolera-
ble for families to live with.43 And patients themselves often later viewed their
manic behaviour with bitter regret after the episode had passed
Yet these charts emit the odour of the values of the day. The four cases which
apparently had been falsely diagnosed as ’mania’ are interesting because they offer
some insight into the doctors’ cultural preconceptions about women, and about
why in Vienna mania was almost exclusively a female disease. Anna S., a Jewish
woman of 42 living in Tulln near Vienna, became aggressive and irritable shortly
after getting her period. Or at least, she started to get it, because at the first signs
she took a cold bath, ’in order to conform to her religious obligations on the
occasion of the Jewish New Year’. For the physicians at the psychiatric clinic in
Vienna, this ’suppressed period’ was therefore of some causal significance. But
the actual occasion of the insomnia and agitation of which she and her entire
family complained was the fact that her husband had hit her after she refused to
relent in her accusations that some neighbour had stolen an armband.
The husband’s version was that she had been ’quarrelsome and shrewish’
(streitsfichtig und zanksfichtig) for the last year and a half and that the armband story
was merely the trigger of the latest episode. The patient had asked the husband to
intervene in these constant feuds. The husband on that day had greeted the hated
neighbour nicely; his wife Anna reproached him energetically and, he said, he
forgot himself and struck her on the back with the flat of his hand. Thereupon
began the events that led her to the psychiatric clinic in Vienna, events which
included restlessness and hearing ’voices’ on one occasion that was never again
repeated. The patient’s sister-in-law agreed with the husband’s account: Anna’s
quarrelsomeness had recently become impossible. The whole family attached
great importance to the premature termination of the last period.
43
Families tended to keep the patient at home much longer with depression, paranoia, neurosyphilis and
’hallucinatory confusion’. In mania, the relatives would request admission to an asylum within weeks of
the outbreak of symptoms. See the statistics in Wilhelm Svetlin, Zweiter Bericht uber die Privatheilanstalt
fur Gemuthskranke auf dem Erdberge zu Wien III, Leonhardgasse 1-5 (Vienna, 1891), 28. David S.
Janowsky and collaborators write, ’Possibly no other psychiatric syndrome is characterized by as many
disquieting and irritating qualities as that of the manic phase of a manic-depressive psychosis.’ In 11cases
involving married manic patients, the spouses either sought a divorce or had already obtained one. The
one exception was a woman who, after 25 years of happy marriage, sent her husband out of town in manic
phases. ’The manic phase is perceived as a wilful, spiteful act,’ the authors note. ’Playing the Manic Game:
Interpersonal Maneuvers of the Acutely Manic Patient’, Archives of General Psychiatry, xxixi (1970),
252-261. Quotes from pp. 253, 258.
44
Eberhard Gabriel notes of psychiatric practice in Vienna today, ’I know many manic patients who are
later not able to identify with their manic behaviour in the slightest after the mania has died away. Some of
these patients had actually caused severe harm to their lives and subsequently would have been very glad
had someone protected them from these risks while they were ill. I well remember a young female patient
who in relatively short time during her manic phase had destroyed her entire social status and could not get
over this after the mania had ended. She committed suicide, but not at all in the context of depression.’
Personal communication.

19
Transferred from the psychiatric clinic to Kierling-Gugging, Anna displayed
none of the classic signs of mania, but instead became conspicuous for making
remarks about other patients. ’She mixes herself into others’ business.’ She was in
a ’boisterous’ (fibermutige) mood inappropriate to the present situation, the doctors
thought. She complained about the food. She was discharged four months later,
claiming there was nothing wrong with her, under the supervision of her husband. 45
What did Anna S. ’have’, if anything? A personality disorder? A situational
reaction to living in a crowded apartment building with an impatient husband?
Both the family and the doctors attributed her behaviour to her menses, and both
colluded in confining her involuntarily for a considerable period. One imagines
that in another culture, one more tolerant of anger in women, Anna’s behaviour
would have been seen as a normal variant of the human condition.
Adele S. was upset when she entered the psychiatric clinic in Vienna because
her ten-year-old daughter had just been accused in school of ’immoral behaviour’
with a boy in the toilet. Therefore Adele tried to set the daughter’s bed on fire, in
order to call the attention of the public to this injustice. On transfer to Kierling-
Gugging, she was diagnosed as manic, being ’garrulous [gesprdchig), emotional,
and cheery without good reason [unmotiviert heiter]’. So far this does not sound like
mania. When, however, we learn that ’she lectures to the doctors about the Social
Question’, we understand that the mania diagnosis might have been an expression
of medical pique about an uppity woman, a woman who happened to have
unbalanced judgment about how one calls the attention of the public to an
injustice.46
Both true and false mania cases are seeded with medical value judgments about
female behaviour. The coarseness of Margarethe’s B.’s appetites for both sex and
food, deemed manic for their voracity, offended the doctors in 1890 at Vienna’s
main asylum. She was transferred to the violent ward, when she and another
female patient jokingly imitated sexual intercourse. A note stipulated that she was
to be separated from this co-patient in the future. 41
Leopoldine G., a twenty-year-old middle-class Viennese woman, had been
something of a trial to the doctors at the psychiatric clinic. She mocked them when
she was admitted, ’and calls upon co-patients to do the same’. She was inclined to
tear up her covers and play as though she were strangling herself. She struck out
at the doctors. And when the staff remarked to her that she must have learned a
’coarse expression’ from a previous co-patient, ’self-confidently’ she replied that
that might be true. ’But everything else I come up with myself!’ (Alles andere habe
45
LIAKG 1900/4.
46
LIAKG 1905/111. The other two ’mania’ cases which in retrospect may have been misdiagnosed were
Barbara S., LIAKG 1902/289, who became totally psychotic and disoriented, losing her early ’manic’
signs; and Johanna T., 1904/236, who also seems in hindsight schizophrenic. Her refusal to cook is
in the chart as a sign of grave disturbance in a woman.
implied
47LIAKG 1892/87. She had an undoubted manic-depressive illness, but these comments were on the
manic phase. The same is true of the next case.

20
ich aber von mir selber!) What would have been seen as normal jollity in a male was
viewed as outrageous in a woman like Leopoldine, especially a middle-class
woman, ’eine Private’, as the designation had it. Such behaviour was diagnostic-
ally important, because when women transgressed these social norms it became
evidence of illness. Leopoldine G. probably did have a major mental disorder, but
she did not necessarily require involuntary confinement. These doctors may well
have equated ’outrageous’ with ‘pathological’.4g
It would be hard to argue that Marie S. was psychotic, but something about her
whole personality just seemed to go against the rules of village life. A young widow
with a child, five months after her first husband’s death she had remarried a local
farmer for his money. Now, after a big quarrel with her new husband a year later,
she found him ’boring’, a ’dumb lug’, and spent as much time as possible away
from home, wandering around the roads, or sitting about the local tavern drinking
with the men. She had wasted money buying excessive feed and went shopping
too often. On the basis of this behaviour, her husband brought her to the medical
officer of health in Amstetten for an assessment. The doctor commented on her
’coquettish nature and her inappropriately fashionable dress’, (kokett-affektives
Wesen, ihre Kleidung für ihren Stand zu gewdhlt), recommending that she be
transported to an asylum ’by forcible measures’. So the husband and the local
mayor took her to Kierling-Gugging. She kept protesting that she was not mentally
ill.
What did Marie S. really ’have’? An acute case of boredom? She said she went
walking because she needed ’fresh air and activity’. A true-bill mania? She did
exhibit some of the symptoms while in the asylum. A bad case of cultural conflict
between men and women? At the asylum she was kept back from doing agricul-
tural work because she tended to come on to the male patients, ’as a result of her
erotic nature’.49 Marie S. probably had an underlying psychiatric illness, but she
also suffered under the distinctive cultural responses of male peasants in Lower
Austria to the personal strivings of a woman, strivings that might have been totally
unconnected to her illness.
A final point about mania: it did in fact occur in men, too, rather than being just
a culture-bound way of expressing discontent on the part of women, or a culture-
bound male way of dealing with that discontent in the form of a psychiatric
diagnosis.5° In some ways, the most quintessentially manic of all these patients
was Karl P., for whose cheery grandiosity and elevated sense of self-importance
48
LIAKG 1901/61.
49
1891/95. She was discharged under the supervision of her husband. Her diagnosis was mania, not
manic-depression. At the end of a long bill of particulars about his wife’s frivolous behaviour, the husband
mentioned as an afterthought that his wife had threatened to kill herself and her child. She apparently
denied this.
50
Still, in Central European context, the female surplus in Vienna is striking. In Mendel’s private
asylum in Berlin-Pankow, for example, 29 males and 28 females had been admitted with mania. Op. cit.,
p. 141. Of 257 mania cases admitted in 1876-96 to the ’Burghölzli,’ which is Zurich’s university
psychiatric clinic as well as the cantonal mental hospital, 89 were men, 144 women. Otto Hinrichsen,

21
there is in these records no female counterpart. 51A middle-classes of a well-
connected family, he was accustomed to ordering people about. And command he
did: when he came into the main Vienna asylum in 1893, a history of insulting
patrons in restaurants and buying sprees behind him, he realized that 31 of his
cigars had been stolen. He demanded that the asylum reimburse him.
In Karl P.’s next admission in 1893, he had just struck a police officer. As the
police doctor sought him out in the tavern where he had been drinking, Karl P.
refused to come along to the commissariat on the grounds that he had a doctoral
degree, and instead invited the doctor to sit down and settle the affair over a glass
of wine. Once at the clinic his ’manic mood continues. The patient declaims
loudly in his room; often he dashes off long poems and fairy tales in a couple of
minutes.’
His admission in 1895 was precipitated by a scene in the restaurant ’Zur Linde’
in the Rotenturmstrasse, to which he had come by taxi. As the driver followed
Karl into the restaurant for his fare, Karl knocked the man to the ground. He
exhibited in all these episodes the standard signs of mania, with a radiantly cheery
mood, pressured speech, and hyperactivity. The doctors noted in this particular
admission that his ’eroticism is visible’, (Erotismus sichtbar), meaning apparently
that he had an erection. Once in the main Vienna asylum, his expansiveness
caused slight ’collisions’ with other patients. He manifested an ’exalted self-
confidence and overestimation of self in his various plans. He wants to learn
languages, writes an enormous number of letters, and makes offers of marriage.’
(He was already married.)
When Karl P. was admitted to the psychiatric clinic the following year (after
having visited ’his friend Krafft-Ebing’), it was late in the evening and the hospital
kitchen was closed. Karl therefore demanded that his dinner be brought to him
from the ’Riedhof, a chic restaurant. (The doctors put an exclamation mark in the
chart). ’A man in my situation,’ he explained, ’deserves better treatment.’ When
transferred to the main Vienna asylum, ’he tells of his many public lectures, uses
much Latin terminology, laughs a lot. His face is very expressive, mobile. The
patient is visibly very content with himself and his manner of speaking, and often
strikes a slightly superior tone.’
But Karl P. was going downhill. His next admission in 1897 was precipitated by
yelling, ’Sons-of-bitches, traitors,’ (Lausbuben, Hochverrdter) and so forth into the
door of the Tiroler Weinstube. The proprietor dragged him to the commissariat,
where the police doctor referred to him as ’a real nuisance’ (eine wahre Plage).
’Statistischer Beitrag zur Frage nach der Häufigkeit der einfachen acuten Manie im Verhaltniss zu den
periodischen Formen derselben’, Allgemeine Zeitschrift fur Psychiatrie, liv (1898), 785-805; statistic from
p. 794. In several American studies, men actually predominate among the mania patients. Paula J.
et al., Disorder. IV.: Mania’, Comprehensive Psychiatry, vi (1965), 313-322; 58 percent
Clayton, ’Affective
of the 31 patients from St. Louis in this study were male. See also Taylor, Archives of General Psychiatry,
op. cit., where, of 52 mania patients seen in New York City in 1972, 56 percent were male (p. 520).
51
But in the private nervous clinics, manic upper-class females did show the same commanding qualities
as Karl P. See the case of the Hungarian countess in the Svetlin clinic, in Shorter, ’Women and Jews’, op. cit
.

22
Yet Karl P. was transferred to Kierling-Gugging later that year, at 46
even as
already tired-looking and greying, he was undaunted in a grandiosity bordering
on megalomania. He immediately unpacked his writings and explained their
‘great scientific importance’, then fired off a number of letters to ’acquaintances in
different German cities’ . 52
The two manias?53
Perhaps there are two forms of mania, the one linked to manic-depressive disease
and genetically determined, the other linked to hardship and misadventure and
socially determined. The nineteen patients discussed above had mania-only,
never a bout of depression. Fifteen other patients, by contrast, alternated between
mania and depression. Some had mainly mania across the years with but a single
bout of depression, others had mainly depression with but a sole episode of mania.
Still others swung regularly between the two, enjoying intervals in which they
were entirely free of illness. I shall not subject these fifteen manic-depressive
patients to a detailed analysis, as the phenomenon of depression at Kierling-
Gugging will be the object of a separate report, and we have described mania
enough to give the reader a feeling for it. But one notes that manic-depressive
illness, or bipolar disorder as it is called today, has become the first psychiatric
illness for which a genetic basis seems to have been established.54 The disease is
probably biological, although stress may be required for its expression. The
implication is that those without the genre will not develop manic-depression,
regardless how much stress they are subject to.
The question is, did the patients whose only symptoms were mania also have an
underlying manic-depressive illness even though they never became depressed?
(Or at least, they did not become depressed before being discharged from
52
LIAKG 1897/28. His diagnosis in fact was manic-depression, but his illnesses were almost all manic in
nature. His first asylum admission had occurred in 1885. The entire case could have been taken from the
pages of Wilhelm Mayer-Gross & Martin Roth, who write, ’The [manic] business man shows unusual
enterprise, is full of plans, which, inspired or not, he regards with uncritical optimism, and takes
considerable and unjustifiable risks in carrying out his ideas. The patient is self-assertive, boastful, and
easily irritated when others fail to conform with his plans.... The past and present he regards with
self-satisfaction, the future with radiant self-confidence. He is in excellent humour with all the world, and
indifferent trifles may tickle him to a loud hilarity. Sexual desire and enterprise are increased....’ Eliot
Slater & Martin Roth [& Wilhelm Mayer-Gross, co-author of earlier eds], Clinical Psychiatry, 3rd ed.
(London, Baillière Tindall, 1969), 211.
53I borrow this phrase from Edward Hare, ’The Two Manias: A Study of the Evolution of the Modern
Concept of Mania’, British Journal of Psychiatry, cxxxviii (1981), 89-99. Yet Hare meant the contrast
between traditional psychiatric notions of ’chronic mania’ and Emanuel Mendel’s and Emil Kraepelin’s
modern concepts. On Mendel, see op. cit. Kraepelin detailed his views about ’das manisch-depressive
Irresein’ in Psychiatrie: ein Lehrbuch für Studirende und Arzte, 6th ed., 2 vol (Leipzig, 1899), vol. II, pp.
359-425.
54
See Janice A. Egeland
et al., ’Bipolar affective disorders linked to DNA markers on chromosome 11’,
Nature, cccxxv (26 Feb., 1987), 783-787. Further: Stephen Hodgkinson et al., ’Molecular genetic
evidence of heterogeneity in manic depression’, ibid. , 805-806.

23
Kierling-Gugging, when we lose sight of them.) If the answer is yes, then argu-
ments about ’cultural expectations of women’ and such will recede into the
background in light of the great impression of biology. If no, then culture will
emerge more clearly as a shaper of the symptoms of the mania-only patients, given
that a good deal of this ’mania’ was the product of social views of what was right
for women.
The tradition of psychiatric diagnosis established by Emil Kraepelin and con-
tinued until today sees mania as a subcategory of manic-depressive illness, not as
an independent psychiatric disorder.55 This classification has been somewhat
controversial because a certain percentage of patients with the diagnosis of bipolar
disorder never, in fact, have the second pole, never are depressed.56 This paper
cannot comment on whether mania deserves the status of a separate disease entity,
simply because most of our mania patients were still too young as we lose them
from view to say whether or not they would later have a depressive episode. What
I want to do here is suggest the possible presence of two different kinds of mania,
the one biologically based and forming a part of manic-depressive illness, the
other possibly culturally-determined and deriving its symptoms in imitation of
the first. Several different kinds of evidence suggest that we may be dealing, in the
34 patients having some form of mania, with two different disorders.
TABLE 2. Average age at first admission to an asylum and age at onset of current illness for
Kierling-Gugging patients. Women only. N 39 =
Table 2 demonstrates age differences for female patients having hysteria,

mania, and manic-depression. Manic-depression began at an earlier age. The
55
See Diagnostic and Statistical Manual of Mental Disorders, 3d ed. revised. DSM-III-R (Washington:
American Psychiatric Association, 1987). ’Mood disorders are divided into bipolar disorders and depres-
sive disorders. The essential feature of bipolar disorders is the presence of one or more manic or
hypomanic episodes (usually with a history of major depressive episodes). The essential feature of
depressive disorders is one or more periods of depression without a history of either manic or hypomanic
episodes.’
56
(p. 214)
Mania alone was seen in 128 of 295 ’manic-depressive’ patients at the Danvers State Hospital around
the time of the First World War. John B. McDonald, ’Recurrence and duration in manic-depressive
Journal of Nervous and Mental Disease,1 (1919), 347-348. A recent study found that among 241
psychosis’,
bipolar patients being treated with lithium at the New York State Psychiatric Institute, 16 percent ’had
never been hospitalized or somatically treated for depression’. John Nurnberger et al., ’Unipolar mania: a
distinct clinical entity?’ American Journal of Psychiatry, cxxxvi (1979), 1420-23. The authors nonetheless
concluded that mania was not a separate disease because the manic patients did not differ from the others
in regard to family history of psychiatric illness or in response to lithium.

24
manic-depressive patients were on an average ten years younger than the mania
patients at the time of their first admission to an asylum (a proxy for the onset of the
first illness, the date of which is usually impossible to determine from the accounts
the patients and their relatives give). Similarly, the manic-depressives were
thirteen years younger than the mania patients at the onset of the current (present-
ing) illness. Of course one reason why the manic-depressives were younger is that
the illness usually starts with depression. Of the 14 women with manic-depres-
sion, only in two did the initial episode seem to be manic.
One might argue that once the manic-depressives got around to their mania
episodes, they might be as old as the mania-only patients. Yet in a number of the
manic-depressives, the interval between the first depression and the first mania
was so short that it could not have contributed significantly to the overall age
difference. For whatever reason, the mania patients emerge as a population of
older women. 57
A second difference is that only 16 percent of the manic patients, as compared
with 47 percent of the manic-depressives, were middle-class. 58 There are several
possible explanations for this. One is that doctors might have taken the ’histories’
of middle-class patients more carefully than those of the lower classes, and thus
elicited details about earlier episodes which would point to manic-depression. A
second is that family members of middle-class patients might have volunteered
more details about the past. (It is unlikely that ’circular insanity’ was a more
fashionable diagnosis than mania alone, for its prognosis was considered to be
hopeless, its cause ’poisoned’ heredity.) A third is that manic behaviour was
57
Of the affective-disorder patients studied by C. M. H. Nunn in Southampton, England, 85 experi-
enced their first episode as depression, 26 as hypomania. ’Mixed affective states and the natural history of
manic-depressive psychosis’, British Journal of Psychiatry, lxxxiv (1979), 153-160, table on p. 156.
Krafft-Ebing, by contrast, was firmly convinced that the majority of first episodes of what he called
’periodic
58
psychosis’ (manic-depressive psychosis) were manic and not depressive. Op. cit., p. 483.
I have assigned patients to social class on the basis of various kinds of evidence. Among the 7
’middle-class’ manic-depressives, Anna Marie B. was a doctor’s daughter, Karl P. was a ’writer’
(Schriftsteller) and clearly middle-class from the context; Amalie S. was the widow of an army major, and
had a daughter working in Bohemia as a private tutor. She also played the piano. Leopoldine G. was ’eine
Private’; so was Helene G., who also played the piano. Ida K.’s father was a government official (Beamter)
who lived in the XIXth district (although she herself gave her occupation as ’seamstress’). And Olga F.
was the daughter of a high-school teacher of the Jewish religion (mosaischer Religionsprofessor), and played
the piano. The lowly Josefa S., a cook with manic-depression, asked about the co-patients on her ward,
’Who are all these highly-placed women?’ (hochgestellte Frauen)
Kierling-Gugging had a piano in this ward. The doctors seemed to think that starting to play it meant
one’s illness was terminating. On the significance of the piano for determining social class, Freud’s sister,
Anna Freud-Bernays wrote in her autobiography, ’We were raised so simply [sehr einfach erzogen] that
even the ownership of a piano seemed to us a sign of great wealth. We ourselves did not learn to play the
piano. But out of her love of music our mother rented one so that we could have lessons. My brother
Sigmund was however so outraged over the beginners’ scales and finger exercises that he threatened to
move out. Therefore the lessons stopped and, to our great sorrow, the piano disappeared.’ Erlebtes
(Vienna, n.d. [1930]), p. 5.
Among the three ’middle-class’ manics, Eduard N. was a borderline case, himself a grade-school
teacher (Volksschullehrer), but his brother was a ’Guttarren-Fabrikant’ in Prague. Leopoldine S. lived in the
XIXth district and wished to be called ’Frau S.’ by the orderlies, rather than ’Sie, S-----’. She was ’eine
Private’, as was Barbara T.

25
deemed more tolerable in the middle classes, and was thus less likely to receive a
psychiatric diagnosis.59
There is, however, still another possible explanation for the high percentage of
middle-class patients among the manic-depressives. Given that properly diagnosed
manic-depression is a genetic disease, and that mania-only may be a separate
disorder, one would expect to find manic-depressive disease throughout the social
order. Let us say we have healthy parents from both middle and lower classes who
carry the gene for manic-depressive illness. The parents are, it is emphasized,
asymptomatic and have normal lives. The children of such parents, whether of
lower class or middle, will all have similar chances of themselves becoming ill.
Once they develop the disease, they may well experience social down-drift, but
that is beside the point: the children born of genetically-disposed but healthy
middle-class parents are as much at risk as the children of similar lower-class
parents. That is why one would expect to find the risk of illness distributed
equally at birth among the various social classes, all other things being equal. 60
Now, a city like Vienna had a huge, impecunious middle class, families with
social pretentions who had once had some money or position but were now down
on their luck.61 Such families could not afford the private nervous clinics, and
would perforce have to send sick relatives to public asylums. These relatives
would have their shaire of manic-depressive illness, as indeed they would have
their just portion of other genetically-determined neuropsychiatric illness such as
Alzheimer’s disease and Wilson’s disease (again, assuming all else is equal).
But pure mania may not be a genetic disease.62 It may be more a response to
59
In general, the incidence of mania in relation to depression seems to diminish as the social class rises,
so that middle-class patients are more prone to mainly-depressive ’manic-depression’ than are lower-class
patients, who seem to have more mania. See Murphy, op. cit., pp. 130-133. Arguing from contemporary
data on the greater frequency of manic-depressive illness (bipolar disorder) generally among the ’upper
socioeconomic classes’, Walter Vandereycken suggests that ’the (hypo)maniac phase of the bipolar
disorder may go more often unnoticed as ’pathological’ because of its more acceptable form in higher social
classes. So it is perhaps not so much a question of mania being more prevalent in lower classes, but of the
form of mania which through a process of cultural shaping corresponds better (is thus more tolerated) with
the norms and expectations of the higher classes.’ Personal communication.
60
But all other things are never equal. Therefore John Nurnberger and associates speak of ’multifac-
torial’ transmission. ’Genetics of psychiatric disorders,’ in George Winokur & Paula Clayton, eds, The
Medical Basis of Psychiatry (Philadelphia: Saunders, 1986), 486-521, esp. p. 494.
61
Ralf Wichmann observed in 1903 that, while the psychiatric care of the well-to-do and the poor in
Germany was provided for in various ways, ’between these two groups remains the large population class
of the so-called educated less-well-off [gebildete Minderbemittelte
]. Roughly all people with a yearly income
of 2000 to 5000 marks are included in this group. This very large group includes the actual educated
middle classes, the petite bourgeoisie [die kleinen Burger], artisans, shopkeepers, many officials, teachers
and so forth.’ ’Eine Nervenheilstatte fur gebildete Minderbemittelte im Harz’, Krankenpflege, ii (1903),
1005-11, quote from p. 1007. Vienna’s anti-semitic mayor Karl Lueger came from the petite bourgeoisie,
and typified their politics. See Carl E. Schorske, Fin-de-siécle Vienna: Politics and Culture (New York:
Knopf,
62
1980), 134-135.
There is little difference between the manics and manic-depressives in terms of family history of
mental illness. One would expect to find more mentally-ill first-degree relatives among the manic-
depressives than among the only-manics, if these two disorders are in fact separate. But the differences,
although in the predicted direction, are not large. For only 1 of 10 hysteria patients had there been a mental

26
grinding hardship and terrible adversity in life’s fortunes. Such adversity would
be much more common among the poor people, who formed the great majority of
public asylum patients, than among the moderately well insulated (though not
wealthy) middle classes. Mania might therefore, as a situational response to
massive misfortune, be commoner among the lower classes. Of course this is
highly speculative. Yet a moment of speculation may not be irresponsible in view
of the evidence of the last section of this paper.
Mania and misfortune

By various indices, the women with mania had hard lives. The mortality of their
infants and children offers an interesting example, as seen in Table 3.
TABLE 3. Mortality of all children born to female patients in Kierling-Gugging

(N of parous women 25) =
* Note: Of the 20 children born to Marie Z., a mania patient, 17 died. Once she is removed from the
mania group, child mortality of these patients falls to 47 percent. LIAKG 1904/188.
Every second child born to the 39 women of the asylum had died. Of the 105
children ever born to them, 53 were dead (50 percent) by the time the mother
entered Kierling-Gugging. This compares with an overall infant and child mortality
(ages 0-5) in 1881-1897 in Lower Austria of 36 percent.63
But this excessive mortality is entirely due to the children of the mania patients:
disorder (or a proxy thereof such as a suicide attempt or a history of alcoholism) in a first-degree relative
(10 percent). Of the mania patients, 26 percent had a ’positive’ family history (5 of 19), three of the 5
having alcoholic fathers, the others with various close relatives who had suicided or been admitted to
asylums. Of the manic-depressive patients, 33 percent had family histories in which mental illness had
occurred (5 of 15): mothers who had made suicide attempts, alcoholic fathers and so forth. These statistics
are almost certainly underestimates, for in a number of patients a family history was never obtained, and
in others the information is vague and cursory: a mother who had once been ’mentally ill’ (geisteskrank) and
the like. But we cannot be sure the underestimation is distributed evenly across the three different groups
of disorders.
63
J. Daimer, Geburten-und Sterblichkeitsverhältnisse in Osterreich wahrend der Jahre 1819-1899 (Vienna,
1902; an offprint from Beilagen 4 and 37 of Das Osterreichische Sanitatswesen [1902]), 79. The great
majority of the asylum mothers’ children who died were under 5, the terminal symptom being most often
convulsions .’Fraisen’
(
)

27
58 percent infant and child mortality, versus 33 percent for the hysteria patients
and 37 percent for the manic-depressives. There could be various explanations for
this apparent astounding ill-fortune. Perhaps these manic women were simply
bad mothers. It is impossible to assess their competence before admission,
although they certainly seemed attached to their children while in the asylum, and
were visited regularly by them. Margarethe B., for example, had become pregnant
outside the asylum in the midst of a fit of mania, and realized once she was
readmitted that she would probably have to give the child up. This preyed greatly
on her mind during pregnancy, and in fact she was quite upset when, after the
infant’s birth in 1891, it was sent to a foster home in Bohemia.64 Perhaps it was
that these mothers had simply had ill-luck, or had contracted syphilis so that their
children were born weak. The reason for this extraordinary mortality is unclear.
Yet in a society such as Austria late in the nineteenth century where tender
attachment to children was the rule65, the loss of so many offspring must have
been profoundly wounding.
A second ’hardship’ difference is that the current illness in manic-depressives
tended to be associated with some traumatic, even catastrophic, one-shot event,
such as the death of a husband, or the discovery, after a stillbirth outside of
wedlock, that one’s fiance was indifferent. In 11of the 15 manic-depressives (73
percent), the present illness had been precipitated by such a traumatic event; in
only 4 of the 19 mania patients (21 percent) had this happened. Sometimes the
traumatic event was a recent delivery. For Franziska L. it was a fire in a
neighbour’s house for which her husband was blamed.66 For Josefa B. it was the
death of her eight-month-old child.6’ For Rosalie L., 20, it was her seduction in
the Prater big Viennese park) by a government official who also gave her
(a
gonorrhea.6 Sixteen-year-old Leopoldine T. had learned two weeks before admis-
sion that she was pregnant.69 And so on. It is quite common for major mental
illnesses to begin with a shock, and these Austrian manic-depressives were no
exception.
What is interesting, however, is how few sudden, traumatic events precipitated
the illnesses of mania-only patients, suggesting that their illnesses may have been
a cumulative response to an entire life of hardship rather than a swift decompen-
sation caused by a single traumatic event. We remember that the pure-manics
were overwhelmingly lower class, the manic-depressives partly middle, partly
lower. Thus we might oppose mania-only, born of a lifetime of unhappiness, to
manic-depressive illness, a genetic disease with a stress trigger.
Some of these charts, it must be said, are just drenched in the tide of human
misery. Anna H., for example, a mania patient, had worked at many posts as a
64
LIAKG 1892/87.
65
This is the argument in Shorter, The Making of the Modern Family (New York: Basic Books, 1975).
66 LIAKG 1904/208.
67
LIAKG 1905/35.
68
LIAKG 1897/4.
69
LIAKG 1893/35.

28
servant since age 12. Out of work at 29, she had got a job as a cook at the army base
in Bruck/Leitha. Even though single, she had already given birth to three chil-
dren. In May 1899 she acquired the delusional belief that one of the soldiers at the
base was about to marry her. She took her 18 guilders pay and bought herself a
new outfit so that she would be pretty. When admitted to the servants’ hospital
(Dienstbotenspital) in Bruck, she spoke of her lover in ’enraptured tones’ (schwdr-

merische Reden). She believed she was not in hospital at all, but in a hall for her
wedding, her bridegroom in the next room, the beds filled with relatives who had
come for the ceremony. Jesus and Mary had introduced her to the bridegroom. As
the court doctor interviewed her, she admitted that the bridegroom ’has not
confessed his love to me yet, but today will be the wedding’. How did she know all
this? ’Our Lord Jesus Christ looked at me so significantly yesterday in the church
next to the cross.’ She was cheery and hyperactive as she told her life story again
and again.
When she had recovered later that summer, she told the members of the court
commission, ’I have no luck at all. I was born under an unlucky star. Others can
stay for years in the same job, but I have to move on because of the gossips.’ (Sie
habe kein Gluck. Sie sei zum Unglück geboren. Andere sind Jahre lang in einem
Dienstposten während sie oft von Mddeln verschwdrzt wiirde.) Her sister added that
Anna always got pregnant the first time by every man she was with. 70
Were these women unhappy because of lifelong chronic illnesses, or ill because
of lifelong chronic unhappiness? It is impossible to sort this out. One has merely
the impression, without being able to quantify it, that the misery level in the lives
of the manics was higher than that of the manic-depressives.
Let us say, however, that as a result of chronic misery someone feels the need to
develop symptoms. Perhaps the purpose of these symptoms is to convey to others
without saying so directly that one is desperately unhappy and wracked with
stress. What symptoms would one adopt?
There may be two mechanisms here, an ’imitation effect’, and the intrinsic logic
of the symptom. On one, whatever the culture deems appropriate one will grasp.
In practical terms whatever one has been exposed to in daily encounters with other
symptomatic individuals, one will imitate. So imitation partly determines how
patients will behave.71 This effect may have steered these unhappy lower-class
women towards mania.
Once Anna H., the mania patient we saw above, arrived at Kierling-Gugging,
she started tearing off her clothes and smearing herself with urine and faeces.
When asked why she was doing it she replied, ’If others do it then I can as well!’
(Wenn es andere so machen, kann ich es auch tun!)72 Marie S., a hysteria patient, later
70
LIAKG 1899/188. Diagnosis: mania.
71
One British psychiatrist has suggested of hysteria patients who simulate the symptoms of schizo-
phrenia, ’Patients seemed to need two to three hospital exposures to achieve this level of nosological
sophistication.’ A. D. Forrest, ’Manifestations of "hysteria": phobic patients and "hospital recidivists" ’,
Journal
British
72
of Medical Psychology, xlii (1969), 263-270, quote from p. 266.
LIAKG 1899/188.

29
told the
Kierling-Gugging doctors that her stay in the psychiatric clinic had had a
powerful suggestive effect upon her. ’I also started yelling and calling for may3
mother and so forth.’ (Sie habe nun auch geldrmt nach ihrer Mutter gerufen u. s. w. )
On two: why would women chose mania rather than depression, certainly a
commoner symptom in our own time? It may have been because of some of the
cultural and medical preconceptions we noted above about women as creatures
close to the loss of control. We have Anna S., the Jewish woman from Tulln, who
was close to losing control because of her ’suppressed period’. Or one might cite
all the hysteria patients whose very symptoms - convulsions and Charcot-style
’iron laws of hysteria’ - suggested that they were on the brink of falling to the
carpet and writhing about. The ’plastic psychoses’, with their histrionic presen-
tations, may thus represent a deep transgression of the social norm that calls for
women to be under control. If indeed this is the true inner logic of these
symptoms, one would wish to ask why women’s desire to make a desperate,
pathological rejection of control varies from social class to class and historically
from period to period.
If the reader will permit one final speculative leap, the experience of these 44
patients may give us some insight into the decline of mania and of its pale cousin
hypomania from the beginning of the twentieth century until our own time.
Giovanni Mingazzini, director of the university neuropsychiatric clinic in Rome,
commented in 1926 upon the recent reduction in the manic component of manic-
depressive illness, and on a similar lessening of the mania seen in neurosyphilis.
Depression on the other hand had become much commoner. 74 Lloyd Ziegler, a
Wisconsin psychiatrist at a private nervous clinic in Wauwatosa, saw by the end of
the 1930s little mania at all among his private patients. ’It is surprising that not
more elations or overactive disorders were elicited.’ He assumed this was because
people with mania do not feel ill nor consider themselves candidates for admission
to a sanatorium. 75 A statistical study of the area around Dumfries, Scotland,
found that rates of mania in women aged 18 to 49 had declined from 10.9 cases per
100,000 female population in that age group in 1880-89 to 3.3 per 100,000 in
1970-79. ~6
Silvano Arieti addressed in 1959 ’the decline of manic-depressive psychosis’.&dquo;
73
LIAKG 1900/197.
74
Giovanni Mingazzini, ’Die Modifikationen der klinischen Symptome, die einige Psychosen in den
letzten Jahrzehnten erfahren haben’, Psychiatrische-Neurologische Wochenschnft, xxviii (6 Feb., 1926),
68-72.
75
Lloyd H. Ziegler, ’Depression as the chief symptom’, Psychiatric Quarterly, xiii (1939), 689-696.
Quote from p. 693.
76
A. D. T. Robinson, ’A century of delusions in South West Scotland’, British
Journal of Psychiatry, 153
(1988), 163-167. The content of manic delusions, however, had not changed. ’About half of deluded
maniacs have grandiose delusions, and at least a quarter have delusions of persecution.’ (p. 165)
77
Silvano Arieti, chapter ’Manic-Depressive Psychosis’, in Arieti, ed., American Handbook of Psychiatry,
3 vols (New York: Basic Books: 1959-66), vol. I, pp. 439-444, on the ’cultural factors’ Arieti thought
responsible for this decline. On the decline of psychotic mania and depression in the twentieth century, see
also P. Niskanen & Kalle A. Achté, ’Disease pictures of depressive psychoses in the decades 1880-89,
1900-09, 1930-39 and 1960-69’, Psychiatria Fennica (1972), 95-101.

30
But of course it was not depression that had declined. It was mania. Without
mania or hypomania there would be no such psychosis. When British psychiatrist
Edward Hare commented in 1974 on the long-term decline in the diagnosis of
’mania’, he noted that whenever severe mania appears today, it is usually ’as-
sociated with physical illness’. Mania’s decline therefore may well reflect, Hare
thought, ’a general increase in the health of adults and their constitutional resist-
ance to disease’ .78
Hare may have steered us in the right direction. Without necessarily invoking
the same mechanism that Hare thought responsible, an increased physical resist-
ance, we might attribute the decline of one of our two manias - ’mania only’ - to
the lessened need in our time for women to be ’steeled for suffering’, to be
psychologically in control of themselves in the face of an immensely hostile
surrounding world .79 The physical misery that characterized women’s lives in
earlier centuries has largely vanished from the twentieth century. Far fewer of
their children die, so women do much less of the grieving so common in this series
of 39 female patients. They need now be less controlled in the face of death
because it happens so rarely. Their husbands are today, generally speaking, less
brutish and beat them up less than the husbands of these Austrian women. One
need be less controlled now about confronting male violence because it happens
more rarely, and when it happens, often justifies ending the marriage. Women
today endure far less frequently infections after giving birth, nor do women now
experience the consequences of childhood rickets with the agonizing, drawn-out
deliveries its residues cause years later. As the very physical experience of
childbirth is obtunded, there is no need to protest one’s misery in histrionic fits,
dramatic flights of ideas, and pathologically compulsive speech. 80
In conclusion, what have we found out about the ’triangle’ of circumstances

mentioned at the beginning that governs the formation of psychiatric symptoms?
First, a powerful biological theme sweeps through these asylums in genetic
predisposition to manic-depressive illness. It is unclear to what extent biology
underlay mania-only and hysteria as well. But the theme of organic determination
of human behaviour, up to now widely ignored by historians, deserves to claim a
place in our agenda of investigation.
78
Edward H. Hare, ’The changing content of psychiatric illness’, Journal of Psychosomatic Research,
xviii (1974), 283-289, quotes from p. 285. In a personal communication Hare said, ’This view of the two
manias might help restore the vexed problem of ’reactive mania’. Perhaps reactive mania in stressed
women has given place to reactive depression.’ On increases in melancholy in the mid-twentieth century
see, for example Olle Hagnell et al., ’Are we entering an age of melancholy? Depressive illnesses in a
prospective epidemiological study over 25 years: the Lundby Study, Sweden’, Psychological Medicine, xii
(1982),279-289.
79
See on these subjects, Shorter, A History of Women’s Bodies (New York: Basic Books: 1983).
80
As for the other mania, the mania of manic-depressive disorder, which also seems to have become less
common, I do not have a good answer. The whole question of ’bipolar disorder’ clearly needs to be
rethought.

31
Second, the role of culture in providing models for illness has been illuminated.
In hysteria the modelling comes directly via medical suggestion, suggestion from
newspaper and magazine articles of the day about ’Charcot-style’ hysteria, and
suggestion from the entire folk culture about fits as an appropriate expression of
distress. It may be also that biologically-determined mania provided a model for
culturally-determined mania.
Third, individual life-histories help us differentiate one kind of illness from
another. We have in mania life histories of cumulated sadness. By contrast,
limited encounters with trauma seem to trigger manic-depressive episodes. What
social class one was born into, whether one’s babies died, whether one’s husband
was brutish - all seem to matter in the choice of symptom.
All of these themes help us differentiate the experience of women in late-
nineteenth-century Austria from that of men. Whether the changes in psychiatric
symptoms that have occurred in the course of the twentieth century have been
influenced by changing patterns of gender relations remains to be determined.

Hysteria, Mania, Gender

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History of Psychiatry

Mania, Hysteria and Gender in Lower Austria, 1891-1905

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Mania, Hysteria and Gender

The history of psychiatric symptoms is of interest because it stands at the

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The path to Kierling-Gugging

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students), but Charcot’s doctrines disseminated widely in Central Europe, and

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psychiatrists. In 1879 Charcot cited Leidesdorf as confirming the universality of

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hystericus, a right-sided hysterical headache and a bilateral contraction of her

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hyperactivity.36 It goes without saying that judgement of these qualities is culturally-

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young people) .41 Yet in at least 14 of the 19 cases diagnosed in Kierling-Gugging

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Although an unmistakable moralizing note about sexuality trails through Josefa

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The two manias?53

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Table 2 demonstrates age differences for female patients having hysteria,

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Mania and misfortune

TABLE 3. Mortality of all children born to female patients in Kierling-Gugging

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(Dienstbotenspital) in Bruck, she spoke of her lover in ’enraptured tones’ (schwdr-

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In conclusion, what have we found out about the ’triangle’ of circumstances

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