Mary V Seeman
email: mary.seeman@utoronto.ca

Keywords: aetiology, history, outcome, schizophrenia, treatment, USA

Views about schizophrenia can change dramatically, even within one lifetime. In order to illustrate such changes over the last forty-five years, this article uses the example of 'Mandy', a composite woman patient with a diagnosis of schizophrenia. It shows that, although there have been many advances over this period, understanding of schizophrenia continues to be elusive, and treatments remain imperfect. Therefore, as perspectives shift and the ground moves beneath us, the psychiatric profession needs to anchor itself firmly in the stories our patients tell us.

woman patient first diagnosed with schizophrenia in the 1950s, adapting over time to her illness and its treatment in a big city in the USA.

I make the point that, although the stories our patients tell us are listened to differently and interpreted differently and responded to differently at different stages of history, our field, for better or worse, must remain anchored in these stories.

Schizophrenia in the 1960s

My involvement with schizophrenia began in 1961 at the start of my psychiatric residency at the Manhattan State Hospital Research Unit on Ward's Island in New York City's East River. I lived close to the hospital for 5 years, which meant that the 30 women who were inmates of the research unit called New Branch III grew to be, in many ways, my extended family [START_REF] Seeman | Therapy in the gray zone: psychiatry recalled[END_REF]. In 1967 I moved my practice to Toronto, Canada, but, over the 38 years that followed, I have kept in touch by letter, by occasional visits and more recently by e-mail with many of the ex-residents of New Branch III.

Doctors still wore white coats and nurses still wore uniforms when I started my residency. But not long afterwards, the concept of the therapeutic community swept in from across the Atlantic and, in my hospital at least, the hierarchy implicit in white coats and uniforms was shed [START_REF] Denber | The therapeutic community: nine years after[END_REF][START_REF] Jones | Therapeutic community practice[END_REF][START_REF] Seeman | Therapy in the gray zone: psychiatry recalled[END_REF]. Not only patients, doctors and nurses, but also maintenance and housekeeping staff were asked for input into individual behaviour management. There was a new belief that the organization of institutions influenced recovery [START_REF] Goffman | Asylums: Essays on the Social Situation of Mental Patients and Other Inmates[END_REF]. Institutions were seen as malignant. The paternalism associated with total institutions soon began to give way to new views that valued patient autonomy and selfdetermination. First year residents at Columbia University were taught that human beings were born with equal potential, tabula rasa [START_REF] Petryszak | Tabula rasa -its origins and implications[END_REF], and, if mental illness struck some of them in their adult years, the fault must, of necessity, lie within their social environment. Correcting the inner environment of psychiatric hospitals became the mission of the 1960s in much of North America [START_REF] Goffman | Asylums: Essays on the Social Situation of Mental Patients and Other Inmates[END_REF]. Since many despaired of ever reforming the poor conditions into which the large psychiatric state institutions had fallen, psychiatric wards began to appear in general hospitals [START_REF] Garner | Role of psychiatric unit of a general hospital[END_REF], and community treatment was hailed as the third great revolution in mental health [START_REF] Rochefort | Origins of the 'third psychiatric revolution': the Community Mental Health Centers Act of 1963[END_REF]. (The first revolution was the removal of chains; the second was the discovery of the unconscious.)

Major tranquillizers, as antipsychotic drugs were first called, were being prescribed for schizophrenia, but many American psychiatrists refused to use them. In the 1960s, the majority were convinced that drugs could only lead to symptom substitution -one symptom dissipating but another coming to take its place -unless the conflict from which symptoms arose were first understood [START_REF] Ayd | Current status of major tranquilizers[END_REF]. The prevalent practice was for the patient with schizophrenia to take drugs during the acute stage of illness only, and then to consolidate gains through psychotherapy [START_REF] Lehmann | The impact of scientific models on clinical psychopharmacology: a psychiatrist's view[END_REF].

Mandy

When I met Mandy, she was 25 and had already been in hospital for eight years. Long stays were not unusual at the time. Several salient points about Mandy's history are: three maternal relatives were long-time residents in psychiatric institutions; her mother was not married at the time of her birth; and Mandy had never met her father. Mandy's mother was always on the road, never spending time with her daughter. The child was brought up by her grandfather who abused her sexually for many years. When she was 15, her grandfather hanged himself in the basement of their home, and Mandy was the one who found him. Some years later, Mandy was apprehended by police while walking carelessly between speeding cars on a highway. She wanted to be run over, she told them, 'to prevent capture by the men from Mars'.

Psychiatric residents were expected to do psychological formulationscoherent chronological stories to help them to understand patients' symptoms. Today I would have heavily weighted the genetic component; in 1961 I barely noted it. Though Franz Kallmann was one of our teachers at Columbia and the results of his twin studies in schizophrenia were widely known [START_REF] Rainer | The contributions of Franz Josef Kallmann to the genetics of schizophrenia[END_REF], genetic determinism, so soon after World War II, was not mentioned in our formulations. The tabula rasa concept was favoured. Today I would have focused on the sexual abuse in Mandy's history; back then I would not have thought it important. The shock of finding her grandfather hanging in the basement I would have considered an important precipitant then, as now, but I put most weight in 1961 on what was, in the USA at least, the accepted explanation for schizophrenia symptoms -parents putting children in double bind situations [START_REF] Bateson | Toward a theory of schizophrenia[END_REF][START_REF] Schuham | The double-bind hypothesis a decade later[END_REF][START_REF] Sluzki | Transactional disqualification. Research on the double bind[END_REF]. This is more or less what I would have told Mandy had she asked me why she was sick: 'Your mother expected you to tell her you loved her but she was never there for you and you didn't love her; you hated her. You couldn't admit it, even to yourself; you couldn't escape either, so your way out was to go crazy.' The 'schizophrenogenic mother', a term coined by Frieda Fromm-Reichmann, was enjoying great currency in American psychiatric thinking [START_REF] Hartwell | The schizophrenogenic mother concept in American psychiatry[END_REF][START_REF] Meyer | The schizophrenogenic mother concept and the TAT[END_REF][START_REF] Neill | Whatever became of the schizophrenogenic mother?[END_REF].

In the 1960s, to learn how to help patients with schizophrenia, psychiatric residents read I Never Promised You a Rose Garden [START_REF] Greenberg | I Never Promised You a Rose Garden[END_REF] by a patient of Fromm-Reichmann and also Autobiography of a Schizophrenic Girl by French psychoanalyst, Marguerite de [START_REF] Sechehaye | Autobiography of a Schizophrenic Girl: The True Story of 'Renee[END_REF]. In this book, the cure takes place when the therapist offers the protagonist, Renée, an apple, symbolic of the breast. The idea was, my supervisor told me, to nurture, but only (of course) symbolically. He himself tended not to be overly nurturing.

Whenever I disagreed with him over patient management, he warned me that my rebelliousness would inevitably increase my patients' symptoms -the Stanton Schwartz phenomenon [START_REF] Denber | The Stanton Schwartz syndrome: three cases[END_REF], a powerful psychological guilt-making theory that had evolved from the belief that institutional events influence patient recovery. I understood from my supervisor that patients were made sick by their parents (read: mothers) and re-traumatized by trainees who disagreed with their mentors.

Our research unit was engaged in the early screening of antipsychotic drugs. At that point several drugs were already on the market and many more were in field trials. Drug trials in the early 1960s were not what they are today. They consisted of clinical observations. There was no blinding and no randomization. Informed consent was unnecessary. There were no institutional review boards. Initially, there were no rating scales, and results were reported in a narrative fashion [START_REF] Cleghorn | The development of psychiatric research in Canada up to 1964[END_REF]. But, after 1962 as an aftermath of the thalidomide calamity, rating scales were made mandatory.

Mandy's treatments in hospital

During the day the dormitory of New Branch III was kept locked so patients could not lie abed. Our patients were expected to work during the day, packaging, sorting, assembling [START_REF] Brooks | Fifteen years of work therapy: its impact on a mental hospital and its community[END_REF]. The profits from work contracts helped the research. One research protocol Mandy took part in was a trial of mescaline, touted for a time as a cure for psychosis [START_REF] Denber | Studies with mescaline[END_REF]. When that did not work, she was tried on a variety of new antipsychotics and did best on butaperazine (Bordeleau, Rajotte and Tetreault, 1964-65), a drug we studied under the code number AHR 712, later marketed as Repoise, now abandoned. Mandy was also treated with a combination of insulin coma and family therapy. The latter was a form of psychological regression therapy in which family members were invited to participate so that healthy, clinically supervised 'rebirth' of the patient could begin [START_REF] Laqueur | General systems theory consideration of insulin and drug therapy[END_REF]. Barbiturates were used for sleep; there were auxiliary therapies of various sorts, including psychodrama, gestalt and token economies [START_REF] Seeman | An account of multiple psychiatric hospitalizations in the 1960s[END_REF].

Due to successful treatment or perhaps to the enactment of new legislation (the Community Mental Health Centers Act; [START_REF] Rochefort | Origins of the 'third psychiatric revolution': the Community Mental Health Centers Act of 1963[END_REF], at age 27 Mandy was released from hospital after a 10-year stay.

Hospital discharge

Many problems faced her when she left the hospital, not unlike those facing newly discharged patients today. One question patients asked, then as now, was: 'How long do I have to continue taking these medications?' The answer we gave to that question, at the time, was: 'Continue medications only while symptoms persist.' A second question was whether or not to live with family who, the prevailing view having been communicated to the patient, had contributed to the original illness. The advice in those days was to stay away from family whenever possible. A third important issue in the 1960s was how the transition to another therapist could most smoothly be made (I was planning to leave the city before too long). Influential work on separation trauma in schizophrenia had just been published, stressing the need for object constancy [START_REF] Burnham | Schizophrenia and the Need-Fear Dilemma[END_REF][START_REF] Searles | Collected Papers on Schizophrenia and Related Subjects[END_REF], so this question loomed larger than it would today. Nowadays I am always shocked by the cavalier (in my opinion) fashion with which residents move from one rotation to another, leaving their patients to the ministrations of others without a passing thought to the impact of the discontinuity.

Another issue for Mandy was work. After some deliberation, she was referred to a sheltered workshop. The expectation was that she would eventually move on from there to competitive work. Mandy asked about the prospect of marriage and family, and we discussed the pros and cons. Although residents did not put genetics into psychodynamic formulations, I recall that, as a profession, psychiatrists were not in favour of patients with schizophrenia bringing children into the world. Not that I recall ever discussing contraception with my patients in the 1960s. We talked to them about sexual fantasies involving their fathers, but we seemed to avoid the subject of sexuality in real time.

Ten years later

In 1972 I caught up with Mandy again while visiting New York City. She was on depot medications and was attending an aftercare clinic, relatively standard practice at that time [START_REF] Lehmann | The philosophy of long-acting medication in psychiatry[END_REF]. She lived in her own subsidized apartment. She had been provided with financial assistance to return to school, had done very well and was now working as a Practical Nurse. Psychotic symptoms were not apparent when I talked to her. Over the course of the ten years since her hospital discharge, she had had several romantic relationships, had become pregnant once and had given the child up for adoption. At that time, this would not have been an unusual step for a single woman to take.

Psychiatry had become the target of labelling theorists in sociology, cultural relativists in anthropology, antipsychiatrists from within the discipline itself, and critical historians of psychiatry [START_REF] Fabrega | Culture and history in psychiatric diagnosis and practice[END_REF]. Revisionism led to the waning of psychological theories about the origins of schizophrenia. Blaming parents for illness was on the way out. Schizophrenia was now commonly spoken about as caused by a 'chemical imbalance' [START_REF] Ban | Myths, theories and treatment of schizophrenia[END_REF][START_REF] Gallagher | The attitudes of psychiatrists toward etiological theories of schizophrenia[END_REF]. Social therapies (engaging the patient in work-related activities and social interaction) had nevertheless been shown to decrease relapse rates over and beyond what drugs could accomplish on their own [START_REF] Hogarty | Collaborative Study Group. Drug and sociotherapy in the aftercare of schizophrenic patients. II. Two-year relapse rates[END_REF]. Drugs plus social rehabilitation were considered optimal treatment. This has not changed.

Twenty years later

Psychiatric diagnoses had now become defined by operational criteria and Mandy's official diagnosis was changed to schizoaffective psychosis. Public confidence in psychiatric classification had been badly shaken over the decade by the Rosenhan study (1973). In this study, pretend patients gained admission to psychiatric hospitals by claiming to hear a voice that said 'empty', 'hollow' or 'thud'. All of them received a psychiatric diagnosis (mainly schizophrenia) even though, once admitted, they no longer complained of any symptom and behaved naturally. In a second part of the study, the hospital staff were informed (falsely) that at some time during the following three months one or more pretend patients would attempt to be admitted. This led to 10% of real patients being suspected of masquerading as pseudo-patients [START_REF] Rosenhan | On being sane in insane places[END_REF]. Tightening up diagnosis was an important advance.

Patients had always found the side-effects of drugs hard to tolerate but by 1982 tardive dyskinesia (TD) was widely recognized as a very prevalent and undesirable long-term side-effect (Ezrin-Waters, [START_REF] Ezrin-Waters | Tardive dyskinesia in schizophrenic outpatients: prevalence and significant variables[END_REF]Task Force …, 1980), especially problematic because it persisted even when drugs were withdrawn and often led to legal suits against psychiatrists. Indeed, when I visited Mandy, her shoulders twitched and she had developed spasms around her mouth. She was no longer working and had started to drink heavily. Drinking was thought of as more a moral flaw than a medical disorder, compared with today, and it was not yet recognized that many individuals with psychotic disorders (almost 50%) drink alcohol to combat the psychophysiological effects of antipsychotic drugs.

Mandy was living with a man considerably younger than herself and, interestingly, had developed a new closeness with her mother. Her mother had joined NAMI, the National Alliance for the Mentally Ill [START_REF] Howe | The National Alliance for the Mentally Ill: history and ideology[END_REF], and had taken up a cause: to debunk the new buzzword in schizophrenia circles, 'Expressed Emotion' (EE). This was a reference to the high levels of criticism and hostility found in a parent's speech when talking about their child, the patient. Levels of EE had been shown to correlate with early relapse in schizophrenia [START_REF] Leff | The interaction of life events and relatives' expressed emotion in schizophrenia and depressive neurosis[END_REF]. NAMI considered this line of thinking to be anti-parent and did not support the research. For the most part, in the USA and Canada, schizophrenia was considered a form of progressive degeneration or atrophy of neural tissue, starting at adolescence, triggered by stress and developing over time [START_REF] Barrett | Conceptual foundations of schizophrenia: I. Degeneration[END_REF].

Thirty years later

By the 1990s it seemed to me as if an about-face had occurred in the theorizing about schizophrenia. Although social deterioration was evident over the course of time in many patients, longitudinal brain imaging studies did not, on the whole, support brain degeneration. New imaging techniques confirmed earlier reports [START_REF] Johnstone | Cerebral ventricular size and cognitive impairment in chronic schizophrenia[END_REF] of intracerebral ventricle enlargement indicative of early brain atrophy [START_REF] Van Horn | Ventricular enlargement in schizophrenia. A meta-analysis of studies of the ventricle:brain ratio (VBR)[END_REF]. Since the enlargement was already detectable at the patient's first presentation to hospital and did not appear to worsen over time, it seemed to point to a stable, nonprogressive early deficit. The thinking became that neurodevelopment (not neurodegeneration) was at fault in most instances of schizophrenia, the inhibition or impairment of the formation of well-functioning neural circuits in foetal life [START_REF] Arnold | Neurodevelopmental abnormalities in schizophrenia: insights from neuropathology[END_REF] through mechanisms still unknown.

Mandy was 56 and clinically not doing well. Her mother had died. Her man friend had disappeared. Whether from alcohol, from grieving, from menopause or financial concerns, the symptoms of Mandy's illness had rekindled [START_REF] Seeman | Narratives of twenty to thirty years of schizophrenia outcome[END_REF]. Despite the stable deficit theory, she now had more symptoms than ever, and they were more severe. She thought enemy agents were following her, slipping powerful drugs into her food, entering her apartment at night, mumbling messages into her ears. Her medication, which had been changed to a low dose 'atypical' antipsychotic because of the TD, was not proving effective. She had several hospital admissions and was once again put on an intramuscular depot. Her TD got worse.

2005

Mandy is now 69. I saw her recently in New York. She is being treated with clozapine, an antipsychotic drug recognized as being effective in about twothirds of patients classified as 'non-responsive'. Her psychotic symptoms are more stable than they were. Her tardive dyskinesia is thankfully gone. She lives relatively contentedly in a seniors' (retirement) home. She has grown very fat. She suffers from diabetes and also from heart disease. Obesity, diabetes and heart disease are too often associated with the use of clozapine and some of the other 'atypical' antipsychotic drugs [START_REF] Casey | Dyslipidemia and atypical antipsychotic drugs[END_REF][START_REF] Miller | Prevalence of diabetes mellitus in patients receiving depot neuroleptics or clozapine[END_REF]. During these last 8 years, she has had both breasts removed due to cancer. Antipsychotic drugs have been suspected of raising the risk of breast cancer in women [START_REF] Wang | Dopamine antagonists and the development of breast cancer[END_REF], although this is not generally believed to be true [START_REF] Sweeney | Risk factors for breast cancer in elderly women[END_REF]. Despite health problems, Mandy has been active. She attends a writing workshop where psychiatric patients are encouraged to write their stories in one of three narrative frames: stories of loss, tales of survival and self-discovery, and narratives of the self as a patient [START_REF] Davies | Silent and censured travellers'? Patients' narratives and patients' voices: perspectives on the history of mental illness since 1948[END_REF]. She has decided that hers will be a tale of survival.

Because of her family history, Mandy is much sought after now to give blood for genetic testing (schizophrenia is currently thought to result from a small number of yet-to-be identified genes, each probably exerting a small effect; [START_REF] Sanders | Influential ideas and experimental progress in schizophrenia genetics research[END_REF]. Being an only child with no descendants makes Mandy an uninformative subject for family linkage studies, but she can contribute to association strategies that compare haplotypes of unrelated affected individuals with those of unaffected individuals. There now exist many genetic clues to possible schizophrenia, 'hot' spots in the human genome that have been linked to the illness, but so far, for want of replication and characterization, these clues remain promising [START_REF] Rutter | Opportunities for psychiatry from genetic findings[END_REF] but tentative [START_REF] Delisi | Critical overview of current approaches to genetic mechanisms in schizophrenia research[END_REF].

In the current age of molecular medicine, psychiatrists appreciate that mutation in the coding sequence of genes or their promoter regions is not the only way to produce illness [START_REF] Guttmacher | Genomic medicine -a primer[END_REF]. As it adapts to individual experience, the nervous system in early life is remarkably malleable, structurally and functionally. In this sense, schizophrenia is now considered a genomic (the result of a disturbance of gene expression) rather than a genetic (the result of a mutated gene) disorder, secondary to a still mysterious interaction of genes and epigenetic factors, some perhaps protective and some presumably pathologic.

Conclusion

Major shifts in causal attribution have occurred over these last forty-five years [START_REF] Thaker | Advances in schizophrenia[END_REF]. As new data emerge, they tend to disprove some and uphold other theoretical assumptions. The study of the history of psychiatry is salutory. It allows the profession to tolerate the incompleteness and ambiguity and mutability of many of its concepts [START_REF] Mulder | Why study the history of psychiatry?[END_REF]. The antipsychiatry movement active in the 1970s and 1980s has, for the moment, become less vocal, perhaps because of rekindled optimism about recovery that has helped to remove some of the stigma associated with mental illness [START_REF] Dain | Reflections on antipsychiatry and stigma in the history of American psychiatry[END_REF].

There are some critics of our current classification system (van Praag, 2000) but most would agree that major improvements have been made in nosology over the last forty years: the standardization of data collection; the formulation of operational diagnostic criteria; the multi-axial approach to psychiatric d i a g n o s i s ; the development of compromise classification systems; the polydiagnostic approach; and, most importantly, the idea that psychiatric diagnoses are hypotheses to be tested and not validated categories [START_REF] Katschnig | New developments in the classification and diagnosis of functional mental disorders[END_REF]. Mel [START_REF] Sabshin | Turning points in twentieth-century American psychiatry[END_REF] has pointed to other major advances: the emphasis on combined pharmacotherapeutic/psychotherapeutic treatment; the alternatives to full inpatient care; and the much improved outcome databases for psychiatric treatments. John [START_REF] Romano | Reminiscences: 1938 and since[END_REF] has underscored: the move from a system of involuntary incarceration and forced treatment in public institutions to a voluntary and pluralistic system; the provision of public and private insurance; support for office, outpatient and inpatient psychiatric care; the resurgence of psychopharmacology; the evolution of multiple modes of psychotherapy; and the pursuit of collaborative research in biological and psychosocial fields simultaneously. Although many have claimed that the new successes of biological psychiatry have made the profession less humane than it used to be [START_REF] Lipowski | Psychiatry: mindless or brainless, both or neither[END_REF], biological psychiatry per se is not a new departure [START_REF] Moncrieff | British psychiatry in the 20th century -observations from a psychiatric journal[END_REF].

What is in store for future Mandys? Through shifts in perspective (which will undoubtedly continue) and despite pressures from health economists, from the pharmaceutical industry, from civil libertarians, from health reformists, and from burdened families, psychiatrists need to carry on patiently elucidating and retelling inner experiences of illness, as did Adolf Meyer (1866Meyer ( -1950) ) and Karl Jaspers much earlier than forty-five years ago [START_REF] Huber | The psychopathology of K. Jaspers and K. Schneider as a fundamental method for psychiatry[END_REF]Winters, 1951-2). However the winds shift, our profession needs to rely on individuals like Mandy to share their stories [START_REF] Kleinman | Basic Books)[END_REF], whether they be of symptoms, of loss or of survival.


Dr Constance Pascal

Felicia Gordon
email: fmgordon@globalnet.co.uk

Keywords: feminism, France, history, Pascal, psychiatry, social history

This article traces the connections between the public career and private life of Constance Pascal (1877-1937), the first woman psychiatrist in France, in the social context of the Belle Époque. Pascal, of Romanian origin, attained professional success at the cost of suppressing her personal life. Best known for her work on dementia praecox, she researched the social as well as the biological causes of mental illness. She founded one of the first 'medical-pedagogic' institutes in France. Her monograph, Chagrins d'amour et psychoses (1935) reflects her wide cultural interests. Until recently, Pascal has been neglected by historians of psychiatry and of French women's history. Her life exemplified many of the conflicts experienced by women entering hitherto allmale professions.

Introduction

Where, as an historical subject, should one place Constance Pascal, the first woman in France to become a clinical psychiatrist? A pioneer in women's professional achievements, her psychiatric writing has recently been the subject of renewed interest (Barbier, 1997; Barbier, Serra and Loas, 1999; Chazaud, 2001; Rees, 2001). Her extensive publications range from an authoritative study of dementia praecox (Pascal, 1911a), through experiments with shock therapy (Pascal and Davesne, 1926), to a more psychoanalytic approach (Pascal, 1935). Her public career, spanning twenty-nine years in a series of large asylums, has been documented (Barbier, 1997). However, there has hitherto been a paucity of information on her private life. [START_REF]Aucune trace de relation sentimentale n'a été retrouvée[END_REF] Newly available sources from family papers (PRFP) have now made it possible to rectify this situation. Pascal's position in psychiatry required a disciplined public persona and, as a woman 'first', an impeccable moral character as that was understood in Third Republic France. In this article I will focus on how the rigorous separation Pascal maintained between her public and private lives illuminates the social history of women entering previously all-male professions. In addition, I will argue that the tensions she experienced between the public and the private found creative expression in her psychiatric work and writing.

Pascal lived a number of different and sometimes conflicting roles: as a Romanian immigrant 2 in a still xenophobic France; as one of the new breed of dedicated professional women; as a clinical psychiatrist; as a researcher in mental illness; and, in her domestic life, as a single mother and educator of her only daughter. To maintain the secrecy surrounding the origins of Jeanne Pascal, her biological daughter whom she adopted, Constance Pascal built a wall of reserve between herself and her professional colleagues. The life of this intensely private family was not, I suggest, idiosyncratic, but symptomatic of the cultural constraints facing women in early twentieth-century France who sought to distinguish themselves in the professions.

The disjunctions between Pascal's professional and private life emerge in any character sketch that one attempts. Contemporary observers speak of her authoritative presence and dignity. She was highly intelligent, proud and, as a young woman, very beautiful. She was superbly well educated in the arts and humanities as well as the sciences. She spoke at least five languages. She had enormous charm, when she chose to exercise it, but did not suffer fools gladly. Her political sympathies were broadly on the left. She was strongly anti-clerical. She was a feminist 'through action, not by public agitation', in the words of her friend, Mathilde Salomon, Director of the Collège Sévigné. 3 She possessed a keen sense of irony. She derived great joy and pride from the educational progress of her daughter, Jeanne. She read widely in history, literature and philosophy. She was an intellectual elitist, who worked all her professional life with society's most marginalized individuals. Internally she was wracked by anger, loneliness and guilt.

Family background and education

Pascal's father, Ion Pascal, a traditionally-minded member of the Romanian landed gentry, had opposed his daughter's educational ambitions. Years later she recalled how her brother Trajan was encouraged to study and to pursue a military career, whereas she, Constance, 'thirsty for knowledge', was expected only to cultivate her personal attractions. She inveighed against the upbringing of girls of good family in Romania:

What are parents' duties towards their daughters? Why do they allow them to study no further than primary school? They are fattened up until their marriage, without being reproached for the food they eat. They are dressed like dolls to go to balls and hunt husbands, without being reproached for the money spent on clothes and the cost of attending functions. They are married off, given a dowry without being reproached and their parents are happy to give their daughters their money. My great fault was to have wanted to study. In my unenlightened family, my education has been considered a useless and costly ornament. [START_REF]Letter from CP to Trajan Pascal[END_REF] Pascal's profound sense of anger and injustice concerning her treatment in relation to her more fortunate brother never left her. In later life she broke completely with her Romanian connections. Reflecting ruefully on her 'family romance', she remarked: 'Decidedly the family, or family feeling is very complicated and I can understand my mad patients who lose it altogether.' [START_REF]Letter from CP to Marie Pascal[END_REF] Her father's death in 1891 freed Pascal to continue her education. In 1897 her family agreed to make her an allowance to pursue her medical studies in Paris. Like many of her class in Romania, Pascal had received a thoroughly Francophone and Francophile education, imbibing Enlightenment culture, though living in a still feudal society. France had become a Mecca of opportunity for ambitious young women, by opening its medical faculties to women students in 1868. [START_REF] Mme | [END_REF] The fact that French women, prisoners of domestic ideology, rarely took advantage of this opening meant that, in the medical faculty, foreign women far outnumbered the French for many years. [START_REF]For the importance of domestic ideology in France[END_REF] To women from Eastern Europe, France must have seemed like a paradise of female liberation and intellectual opportunity. For them French cultural norms and male anxieties about gender were mild in relation to the still rigid class and gender structures of their own countries. Fortunately for foreigners perhaps, through French eyes, they could be viewed as exceptions to the rule of obligatory femininity and domesticity. Still, whether French or foreign, women entering higher education and the professions assumed a symbolic importance out of all proportion to their statistical numbers. These women saw themselves and were seen, as role models, whether pioneers or rebels.

As a medical student at the turn of the century, Constance Pascal fitted the paradigm of the 'new woman' by virtue of her remarkable spirit of independence and her ambition, although it is doubtful whether she would have accepted that description for herself. Whereas the new woman of the Belle Époque was popularly seen as flouting convention in her love life, profession, dress sense or sporting ambitions (much was made of the liberating effects of the bicycle), many talented women took care to avoid a flamboyant life-style, or indeed to rock the boat, in relation to gender roles (Roberts, 1994, 2002). Professions such as teaching, medicine, law and psychiatry demanded of women, far more than of men, discipline, dedication and especially social decorum. In state-funded services like education and psychiatry, the advantages of secure conditions of service (automatic promotion, statutory sick leave, annual holidays, pension rights) were often tempered by a sense of marginality and social isolation, well documented in the lives of 'institutrices' and women lycée teachers (Margadant, 1990: 4). In her first psychiatric posting, Pascal would discover how debilitating this isolation or exceptionalism could become.

If they were not overt rebels, these exceptional women nevertheless saw themselves as feminist innovators by opening their professions to others and by serving as role models for subsequent generations. Pascal's perception of this role emerges clearly in an article she wrote in her mid-fifties on the competitive examination for asylum doctors (le concours du médicat) of 1933:

Three women swept to victory and I hope fame. Three more women civil servants [asylum doctors formed part of the civil service] in present-day society. It is an unbeaten record by feminism in the concours du médicat. In that far-off period when I presented myself for the examination [1908], the question of whether women had souls or not was still being discussed. In this last examination, the only dispute was on the quality of the examination answers, and I had the strong conviction that if all my colleagues are not feminists; they were in no way hostile towards the candidates. The professional question that arose, one useful for women, is the following: can a woman manage a male [psychiatric] ward? Now, I began my career at Clermont in a male ward, then I ran another male ward at Prémontré and at Châlons. At Moisselles, where I was a director, I had men working under my orders. I never had a problem with maintaining authority. [START_REF] Cp | Réflexions sur le concours du médicat des asiles de 1933[END_REF] This is an almost direct refutation of the arguments of Dr Edouard Toulouse who, though a supporter of women's rights, had argued that women asylum doctors would lack authority with male patients and male staff. [START_REF] Dr | La femme et les functions publiques[END_REF] Toulouse, generally a liberal on gender issues, was not one of those who wondered whether women have souls, but he saw the subversive significance of granting women administrative and professional authority in one of the major public institutions of the Third Republic, the psychiatric service.

Pascal said that she entered psychiatry because the limited income from her Romanian family was insufficient to launch her medical career. 'I left the hospitals [of general medicine] because in order to be an intern in general medicine one must be rich. One is not paid. In the asylums, I had enough to live on.' 10 She passed the internat examination in 1903 and the concours for médecin-adjoint des asiles in 1908. [START_REF]Pascal's naturalization (1907) was a requirement before she could sit her psychiatric examinations in 1908. For legislation relating to naturalization in France[END_REF] Psychiatry also attracted Pascal as an intellectual challenge and one in which she hoped to reform the often-punitive treatment of patients. What moved people from normal to abnormal states of mind? She wrote: 'We know that the mad person is a passionate being, every day revealing to us a world of facts that sharpens our curiosity. I have remained fascinated by all the mysteries of their thoughts.' [START_REF] Cp | Médecin des hôpitaux psychiatriques[END_REF] Her choice of profession, then, was a safe economic option, a compassionate response to suffering and a possible route to unravelling the complexities of the mind. What was never in doubt was that she was determined to escape the stultifying life of the Romanian gentry and to succeed in a professional career.

Feminism

How did Pascal see her position in relation to the developing French feminist movement, forefronted in psychiatry by her colleague, Madeleine Pelletier? These two ambitious women, contemporaries, both interns in psychiatry at Ville Evrard, illustrate diametrically differing approaches to advancing the cause of women. Pelletier, who grew up in great poverty in Paris, stressed her working-class roots as well as her feminist convictions. It was Pelletier who in 1902-3, with the help of the feminist paper, La Fronde, orchestrated the campaign to give women access to the examination for psychiatric internships. Pascal did not take part in this very public campaign, almost certainly from motives of prudence arising from her foreign status. [START_REF]To gain French naturalization, a 10-year period of good behaviour was required; overt feminist agitation would not have qualified as good behaviour. Feminists were not only ridiculed in the press, they were considered subversive and were routinely[END_REF] However, both she and Madeleine Pelletier trained at Ville Evrard in the eastern suburbs of Paris at the same period. It is difficult to imagine two more contrasting types. Madeleine Pelletier, short and pugnacious, advertised her feminist convictions by wearing tailored 'mannish' suits and cutting her hair short. Constance Pascal, by contrast, tall and elegant, with a magnificent mane of beautifully arranged black hair (Fig. 1), combined charm, decorum and aristocratic authority.

Pascal's triumphant success on her doctoral thesis was lauded in the press as both a feminine and a feminist success. Her dissertation Formes atypiques de la paralysie générale: prédominance régionales des lésions dans les méningoencéphalites diffuses (1905), gained the full approval of the jury, which included professors Roger, Brisaud, Gaucher and Carnot. They awarded her a 'Très bien', the highest mark:

Feminism can be proud of this new success, especially as Mlle Pascal, while devoting herself to science, has succeeded in retaining the exquisite charms of womanhood. The audience who attended the 7 June defence of her thesis did not know which to admire more, the ease with which she dealt with the most difficult questions of mental medicine or the tact and feminine wit which guided her answers. 14 A contemporary male intern at the Asylum of Ville Evrard, remembered Pascal and Pelletier in a passage equally redolent of the gender expectations of the Belle Époque:

I should mention the feminine phalanx that occupies today an evergreater place in our ranks. I will only speak of those who were the first and with whom I lived in the staff room: Constanza Pascal and Madeleine Pelletier, who were in the first wave of women interns. Constanza Pascal, born a Romanian and naturalized French, then in all the glory of her youth, merited the double epithet that the historian of the Middle Ages gave to one of her predecessors, a professor at the [medical] school of Salerno: Constanza Calenda, as beautiful as she was learned. Madeleine Pelletier was born in Paris; obsessed by her theory of the absolute equality of the sexes, she would have rejected as an insult the first of these epithets [beauty]; she endeavoured, by her dress and her manners, to let no one have the idea of applying it to her. She became notorious in the suffragette period. I don't know what happened to her. [START_REF] Courbon | What happened to her' (Pelletier) was one of the silent tragedies of the inter-war years. Arrested on the charge of assisting in an abortion, she was judged incapable, having suffered a stroke, and was interned in the Asylum of Perray-Vaucluse where she died in[END_REF] It is not hard to imagine that Pelletier would have bridled at Pascal's elegance and class assurance and that Pascal would have found Pelletier's touchiness and feminist militancy rebarbative. Did Pascal consider herself to be a feminist? A feminist commitment may seem unlikely, given her lack of militancy in feminist groups and the journalistic paeans to her femininity. Such a view is certainly mistaken (Gordon, 1990: 70-1; Sowerwine, 1988). Pascal retained a visceral sense of women's inferior status. She held fiercely to the dignity conferred on her by her abilities and her professional status. She fought for the improvement of nurses' training and conditions of service in the hospitals where she worked. She was proud to have been the first woman to serve as an expert medical/ psychiatric witness on courts martial dealing with shell-shock victims; she welcomed during her lifetime the growing number of women seeking psychiatric posts, and she brought up her daughter to be intellectually and financially independent. As we saw in her career summary above, she did not claim to suffer discrimination in her professional life. Yet in her conflicts with the hospital administration, and particularly in her perceived need to conceal her personal life, she experienced what were in reality the effects of social inequality relating to women.

Early career and publications

Following Pascal's career path through a series of hospitals and her research record, in parallel with her complex private life, we can appreciate the efforts she undertook to maintain her confident and authoritative public persona as well as her privacy. Her first two psychiatric posts at Clermont de l'Oise (1908-17) and Prémontré (1920-22), both in Picardy, coincided with the war and post-war traumas of a ravaged country. The Asylum of Clermont, fairly typical of the large and overcrowded psychiatric hospitals of the period (Foucault, 1961; Goldstein, 1987; Porter, 2002; Scull, 1979), was in a provincial backwater. Seriously understaffed when Pascal arrived there, the hospital had 140 nurses for 1673 patients. Hygiene was abysmal; typhoid and tuberculosis were common. The large number of the criminally insane sent to the hospital had resulted in its being turned increasingly into a prison. In the words of a former director (quoted in Teillet, 1983: 24):

When one enters this asylum … one gains a sinister impression. Asylums should be cheerful and give the idea of tranquillity where the patient, whoever he be, comes to recuperate and to rest after a breakdown, or mental fatigue, which has destroyed his reason. This asylum gives the impression of a penal colony.

Pascal was soon forced to abandon whatever hopes she might have had to reform asylum practice. She felt herself to be only a cog in a huge institution and, being obliged to live in the asylum grounds, subject to almost as much surveillance as the patients:

One would need a volume to describe the organization of the Clermont Asylum. Someone has written a book, called The Penal Colony for the Mad which indicates how excellent the organization is. That was seven or eight years ago. But now it is the Penal Colony for Psychiatrists. [START_REF] Cp | [END_REF] However, a newspaper article of the same period (c.1912) described Pascal in glowing, almost Florence Nightingale terms, painting a much more positive picture. The reporter eulogized her for the reforms she had introduced and for her soothing, feminine qualities:

This woman, the only one to have successfully passed the examination for doctors in mental hospitals, has lived for the past three years devoted to the most thankless of tasks, in this solitude, in the midst of a population of degenerates and the demented to whom her care brings a little relief and her presence a bit of joy. For Mlle Pascal is young and beautiful and when she passes through the wards, gloved and her hair beautifully arranged, with an authoritative gesture and look, the most agitated patient pulls himself together for a moment in her presence and asserts his weak powers of inhibition remaining to him, to restrain his furies and his foul language. All these unfortunates felt in some sense that underlying the doctor's medical wisdom was a woman's pity and, without always understanding, thanked her for her goodness. One of them, an epileptic said to me: 'Ah, if she were not here, what would become of us?' Mlle Pascal has forbidden punishments and has abolished strait-jackets. 17 Pascal's first years at the hospital appear to have been fruitful, both in psychiatric practice and in research. She published a series of clinical studies of dementia praecox (Pascal, 1906a, 1906b, 1906c, 1906d, 1907a, 1907b, 1907c, 1908, 1911a). These culminated in her monograph, La Démence précoce (Pascal, 1911b). Though dementia praecox would be superseded as a diagnostic concept by schizophrenia in the succeeding decades (Bleuler, 1911), Pascal's monograph remained a reference text on the subject in France into the 1950s (Barbier, 1997: 77). 18 Pascal had made dementia praecox her principal subject, under the influence of her supervisor at Ville Evrard, Dr Paul Sérieux, an enthusiast for the work of the German psychiatrist Emil Kraepelin (1856-1926). Although it is sometimes claimed that the French scientific climate could be hostile to German ideas (Morel, in Barbier, 1997: 76), Pascal actively engaged with German psychiatric research. For example, she read Jung and Freud at least a decade before they were translated into French, or were widely made known to a French public. [START_REF]Freud's work did not appear in France until 1922[END_REF] Pascal praised the key role that Kraepelin, whom she evidently admired and with whom she had corresponded, had played in identifying dementia praecox as a syndrome. [START_REF] Kraepelin | [END_REF] La Démence précoce dealt with the history, nosology, symptoms, characteristic mental weaknesses, development, organic basis, possible causal factors, pathology, diagnosis, relevance to legal medicine and (briefly) treatment of the disease. Pascal (1911b: 304-5) 21 noted especially its effect on the young:

The frequent appearance of dementia praecox during the student years (childhood, puberty, adolescence) leads educators into many errors. Most of these young patients are confused with abnormal children, or considered to be vicious, badly behaved, lazy, stubborn, etc., and become the recipients of punishments and disciplinary sanctions. Often dementia praecox attacks brilliant pupils, who are the pride of their parents. After having shown an intellect full of promise, they learn nothing more; they become incapable of evolving, of acquiring new knowledge and of submitting to regular labour.

Although focusing principally on diagnostic signs, Pascal also traced the social dimension of the disease. A concern with juvenile delinquency and the treatment of children and adolescents in prisons and psychiatric hospitals marked her subsequent career.

In a rather different context, Pascal's 1908 article on the composer Schumann provides evidence of her cultural interests. Like Maupassant, Van Gogh, Dostoevsky and a host of other nineteenth-century artists, Schumann's mental afflictions have received a great deal of scrutiny from historians, as well as from psychiatrists (Basch, 1928/1936; Ostwald, 1985; Stricker, 1984; Taylor, 1982). Pascal's choice of title, with its plural ('The mental illnesses of Robert Schumann'), contributed to the still unresolved debate about Schumann's madness, expanding Pascal's previously developed thesis (Pascal, 1906c) of the possibility of distinct mental illnesses existing in an individual over time.

The central cultural question that drew Pascal to Schumann concerned the relation between genius and madness: 'His whole life was nothing but a battle to the death, without respite and without a truce between two powers, that of expanding genius affirming and defending itself and that of his illness which devoured little by little his body and soul' (Pascal, 1908: 99).

Was this the genius of madness, or genius responding with insight to periodic mental instability? Pascal argued that from the ages of twenty-one to forty-one Schumann suffered from a constitutional illness, physical in origin and probably hereditary but not from general paralysis, nor dementia praecox. From forty-one onwards, he fell victim to a different illness, which took a progressive and fatal form. The earlier neurosis and the later disorder were, she believed, separate phenomena. It was the concept of genius itself and whether it was not only allied to, but even a product of, madness that most intrigued Pascal. She rejected the Romantic concept of the sick soul as the basis of great art. Describing Schumann's final collapse, after he had been obliged to resign his post as conductor at Dusseldorf, she evoked Nietzsche:

For the mind as for the body, to abandon work is to begin to die. This genius of sound put out its torch. A terrible illness, which pardons no one [this would probably have been the onset of terminal, tertiary syphilis (Quétel, 1992: 139-75)], robbed him progressively of all his faculties: his will, his intelligence, his exquisite sensibility, and the fecund source of so many beautiful artistic creations. He disappeared like Nietzsche's superman 'at the moment when he had attained the highest degree of wisdom, at the moment where the sun of his existence was at its zenith, at the hour of noon, consecrating by his death the triumph of his doctrine.' (Pascal, 1908: 113) We find in Pascal's 1914-18 war journal (PRFP) frequent references to superior minds battling mediocrity. She read Schumann's illness as paradigmatic of those gifted individuals whose nervous constitutions could destroy them, a fate she may have feared for herself. She sought to establish the sanity of genius, to demonstrate that through the power of art, genius could escape from the prison of mental torment. Implicitly she aligned herself with Nietzsche's exceptional individuals.

War and love

In 1914 Pascal's reforming agenda at Clermont came to a standstill. She had hoped to create asylum schools, outpatient psychiatric services and family colonies for the less severely afflicted patients. All these plans were halted by the outbreak of World War I. Clermont was briefly occupied by the Germans in 1914 and thereafter was never far from the front line. Unlike Prémontré which lay within German-occupied France for the duration of the war, the patients were not evacuated, but conditions for all civilians were harsh (Becker, 1998; Blancpain, 1983; Gaines, 1918; Macintyre, 2001; McPhail, 1999). To live in this region during the war years was to experience first hand 'the irreparable and incomprehensible catastrophe' of the German invasion (Duroselle, 1995: 436) The vulnerability of the asylum population, condemned to food and fuel shortages and terrible hygienic conditions, was a daily reproach to medical staff. According to Pascal, the director, a vain and dictatorial individual, neglected his patients: 'The dormitories are dirty, mattresses and blankets need changing, there are lice in the beds -flies and mosquitoes everywhere'. The staff were cowed: 'It is comic to see these terrorized beings before a little, vulgar, choleric, impulsive, violent man.' [START_REF] Pascal | [END_REF] Pascal's journal records the continual boom of cannon, the sound of artillery fire, patients' complaints about food shortages, the loss of asylum staff to the war and reception of shell-shocked soldiers at the hospital. She dwelt on her mounting unhappiness, her conviction that she was being watched and that her rooms had been searched. She seemed caught in a static world while the war raged around her. Her patriotic feelings for France clashed with her concern for her native Romania and her fear that it would side with Germany rather than the Western Allies. Cut off from her family by the war and by quarrels with Trajan over the family inheritance, she was plunged into an abyss of boredom, homesickness and guilt.

How have I been able to stay here so long? How has my destiny not allowed me to have another life? I feel strong and capable of being useful … I cannot bear to pass my time in sighing and mulling over old ideas, in feeling so profoundly the misery of living in a milieu without affection and without warmth … The Russians are in retreat … Nothing heard from Romania. The English abandon their trenches. There are only the French who are admirable. There are only the French who resist and who would rather die than surrender. 23 In a world devoted to the drama of war, Pascal felt crushed by inaction. Yet to speak of idleness is deceptive. She was fully engaged in her hospital work, visited patients in Clermont when their own doctor fled the region, an initiative for which she narrowly escaped official censure, and wrote numerous articles for the press. [START_REF]Over a 4-year period, from 1914-18[END_REF] But she felt the war dramatized women's exclusion from meaningful action. Confinement to life in a provincial asylum came to seem increasingly unbearable. On 9 June 1915, sounding a Bovaryesque note, she made this despairing entry: I suffocate here. I must leave. I want to live in Paris that home of solidarity, that nest of generosity. Here, egoism and avarice crush me. I continually have heart pangs and experience moral and physical weakness. I feel enfeebled and diminished. Time passes in an identical state of l i f e l e s s n e s s . 2 5 Yet shortly after, in the summer or early autumn of 1915, this comment appears: 'I had a discussion today with an interesting man, though like all intelligent men, he has his prejudices.' 26 This entry was the first of a series of reported discussions on politics and army strategy with General Justin Mengin, Commander of the 6th Army Brigade, who had been quartered at Clermont de l'Oise in the Fitz-James Château, adjacent to the hospital. Mengin, ebullient, charming and intelligent, was the son of a schoolteacher. He had early shown intellectual promise, winning a place, first at the Lycée Charlemagne in Paris and then at the p r e s t i g i o u s École Polytechnique where he graduated in 1876. Mengin was 59 years old when he met Mlle la Doctoresse Pascal. Photographs taken in the war years show a robust man with the Clemenceau moustaches of the day; see Fig. 2. He had a successful career behind him, having risen steadily through the ranks. He served in the Artillery and was attached to the General Staff. [START_REF]Mengin was promoted to Lieutenant in 1878[END_REF] He was a good example of the Third Republic's commitment to meritocracy.

General Mengin was also a married man. It is possible that he first encountered Pascal when he came to consult her about his wife, Marie Gabrielle Nicolas Mengin, who four years later, in 1920, would be interned in the asylum of Evreux and who may already have been suffering from mental illness. 28 Pascal was 38 when she and Justin Mengin met, desperately lonely, socially isolated, anguished about the progress of the war and the fate of her family in Romania. Their love affair must have astonished them both. Was their marriage ever a possibility? Under French law Mengin could not FIG. 2. General Mengin, c. 1914 (source: PRFP) divorce if his wife was detained in a mental hospital. [START_REF]The law of 1884 which liberalized divorce in France, forbade it in cases of patients interned in asylums[END_REF] We know she was interned in 1920, but may have resided in another hospital previously. [START_REF]It has yet not proved possible to disentangle the story of Mme Mengin further. Forty-six when she married Justin Mengin, they had co-habited for 20 years, unable to marry before, as Marie Nicholas lacked the private[END_REF] Commenting on a similar case of one of her patients, Pascal would remark: 'I have seen many husbands file through my office who want to cut the leash; it can't be done.' [START_REF]Letter from CP to Director[END_REF] Mengin may have been one of those husbands.

Our only clues as to subsequent events come from the official asylum dossier (Clermont DACP). Pascal must have realized she was pregnant sometime in November 1915. Her pregnancy constituted a major professional and personal crisis, yet she deeply desired a child. But with her whole career at risk, secrecy was imperative. She obtained leave on 1 April 1916 'for reasons of health', later explained in her dossier as 'a surgical operation', assumed to be of a gynaecological nature. [START_REF]Oise to the Director of the Asile d'Aliénés[END_REF] With the assistance of a loyal friend, Jeanne Streicher, Pascal booked into a Paris nursing home. [START_REF]Maison de Santé, 219 rue Vercingétorix[END_REF] On 22 April, with her leave nearly expired but the baby not due until July, Pascal applied for a further three months' leave, sending medical certificates as justification. She finally returned to her post at Clermont on 16 August, exactly one month after the birth of her daughter, Jeanne, on 17 July 1916. The birth certificate (Fig. 3) simply records: 'daughter of unnamed father and mother'. There is no surname; 34 when formally adopted in 1924, the child was given her mother's family name. Unwilling to remain at Clermont where she had been so unhappy, Pascal effected a temporary transfer from Clermont to la Maison Nationale de Santé at Saint Maurice, Charenton. Having initially put her daughter in a nursery, she now fostered the baby, listing the General and Jeanne Streicher as co-guardians. Here, closer to Paris, she was much happier. This position paved the way for her next posting to the asylum at Prémontré, where she was appointed médecin-chef on 17 January 1920, the first woman to achieve that position in a psychiatric hospital in France.

Post-war career

Prémontré was a former monastery, situated some three kilometres on the German side of the Hindenburg line and nearly destroyed during the 1914-18 war. The patients, deprived of doctors, had remained in the care of sisters of charity. Of 1300 patients, 539 died of malnutrition or typhoid in the first year of the war. By 1918 the splendid buildings of the Prémontré order, dating from the eighteenth century, were in ruins (Charpentier, 1921). Even today, the facades remain full of shell holes. Reconstruction began in 1919, but when Pascal arrived in January 1920, with a four-year-old child, she found a chaotic situation; the buildings were in ruins and patients were wandering about aimlessly. Her brother, Trajan, who was in the Romanian legation negotiating the Versailles Treaty, helped with her move -evidence of a family rapprochement at this period. Little Jeanne was 'explained' to her brother and sister-in-law as a fostered war orphan. The official Prémontré dossier makes no mention of Pascal's child, a solitary clue being in the inventory of Pascal's effects that includes a child's highchair. General Mengin, now retired, was also in evidence and enjoyed friendly relations with the director. 35 However, the hospital, staffed by nuns, resisted Pascal's efforts to reform punitive asylum practices. 36 She commented acidly: 'I upset firmly held ideas, beliefs and habits. In this closed-off milieu, the fresh air of a living civilization can only penetrate with great difficulty.' [START_REF][END_REF] Whether for this reason, or the strain of living in deplorable conditions with a young child, Pascal fell ill with a combination of nervous and rheumatic symptoms. She served only 1 1 /2 years of her 2-year appointment at Prémontré before successfully applying to move to Châlons-sur-Marne (Prémontré DACP).

At Châlons, Pascal found a more compatible milieu. Assisted in her move by General Mengin, she was given decent accommodation and was able to devote herself creatively to her work. She almost immediately began to implement a project she had been contemplating since Clermont: the creation of outpatient services for handicapped children (service ouvert pour enfants anormaux). Pascal submitted her plans to the Commission de Surveillance on 21 June 1922, which approved them. [START_REF]On the movement to create open psychiatric services in France[END_REF] She then went on to found, on 18 July 1923, one of the first Instituts Médico-Pédagogiques in France. She argued that 'les enfants anormaux', like all children, should be taught by trained teachers. She wanted her institute to serve the children of the Marne region in order to avoid separation from their families. She travelled all over France to find those children formerly sent away from the locality. The Minister for Health congratulated her for having organized, 'on principles of the greatest humanity, a school for handicapped children, which served as a model for other new schools in France'. [START_REF]Prefect of the Département de la Seine[END_REF] Pascal's work was also highly praised by Georges Heuyer, an important reformer of education for children with learning difficulties (Gaillac, 1971; Heuyer, 1914).

The subsequent history of Pascal's groundbreaking initiative was less fortunate. The combination of outpatient services for children and learning opportunities that she had instituted at Châlons began to be dismantled soon after her departure in 1926, when she moved to the Paris region. In 1930 Georges Heuyer wrote to Brisac, a former prefect of the Marne, lamenting the decline of the Institut Médico-pédagogique at Châlons, 'which had rapidly gained a legitimate fame, for it responded to an evident need and gave excellent results.' [START_REF] Brisac | [END_REF] For her part, Pascal protested vigorously about the Institute's new policy of only taking children with moderate learning difficulties and banishing those with more severe difficulties to other departments. 'The Marne could not look after them, find them a little place in the sun of their family home. It is heart-breaking, painful, distressing.' [START_REF]Asile de Châlons-sur-Marne[END_REF] Meanwhile, little Jeanne Pascal continued to thrive. General Mengin, a frequent visitor, was proud of his bright and energetic 'god-child'. In 1924 Pascal was able formally to adopt her daughter, a move made possible in 1923 by a change in the law that previously allowed only adult adoption, the great number of war orphans having made the adoption of young children a pressing issue. Pascal seems to have acted speedily to ensure her child's legal status and to give her a name. But there was still no question of either parent recognizing their daughter as their own.

Pascal was the first woman to succeed in the competitive examination for médecin-chef of the Seine Department (an additional hurdle for those seeking posts near Paris) and was appointed Medical Director at the Asile de Moisselles in February 1926, a relatively small hospital (332 inmates). Its patients were women, many of them elderly, and children. The death-rate was high: in 1926, 11 women and 43 children died. From Pascal's official report, it is evident that she was deeply disturbed by the dreadful facilities, particularly for the children, and the toll taken by preventable illnesses. [START_REF] De | [END_REF] Tuberculosis, typhoid and the ravages of hereditary syphilis as well as common childhood diseases (mumps and whooping cough) all thrived as a result of poor hygiene and the impossibility of isolating patients: I emphasize the regrettable defects in this service: crowding and insufficient hydrotherapy, which facilitate the growth and propagation of germs. For more than 100 incontinent children, we have not had a single bath; hot water is lacking everywhere. We have been obliged to organize regular baths for the children in the women's bathing areas. 43 When she attempted to put the educational schemes undertaken at Châlons in place at Moisselles, she ran into administrative intransigence based on a desire to save money and on the view that only 'educable' children should receive instruction (Duché Didier, 1990).

As she did in all her further annual reports, Pascal was at pains to praise the nursing staff's efforts:

I am happy to be able to make mention of the devotion of nurses and assistants; they have fulfilled their posts with courage, patience and vigilance, and it is thanks to their exceptional qualities that we have been able to limit the three serious epidemics that reigned during six months in the children's ward. 44 Pascal's forefronting of the contribution of female nursing staff relates to her broadly feminist concerns. Although she is always referred to as the first woman in French psychiatry, the reality was that psychiatric hospitals had always been largely staffed by women, often poorly trained and badly paid. Women were the backbone of the system, though not in positions of authority. Pascal never forgot that the gruelling day-to-day care of her patients depended on an army of mostly forgotten women. They in turn were devoted to her. 45 Appointments to psychiatric hospitals in the Seine region were much sought after. In 1928, two posts became available, one at Perray Vaucluse, to the south of Paris, and one at Maison Blanche in an eastern suburb. Pascal, eager to work in a larger, more prestigious hospital and to be closer to Paris for the sake of Jeanne's schooling, applied for and was appointed to the latter. In her nine years at Maison Blanche while actively engaged in research, hospital administration and patient care, she closely supervised her daughter's education. She was determined that Jeanne, disadvantaged by her birth, would have all the intellectual preparation necessary for a successful life. But the shadow of illness darkened Pascal's final years. At the moment that her professional position was secured as médecin chef at Maison Blanche, she was diagnosed with breast cancer; she underwent a mastectomy in 1928 and could never have been free of the fear of recurrence thereafter.

Later research and publications

From 1926 to 1937, Pascal continued with an ambitious programme of research and publication. These works can be divided into two phases: those dealing with shock therapies and her more psychoanalytically-based research (Pascal, 1935). From a lay perspective, works such as Le Traitement des maladies mentales par les chocs (Pascal and Davesne, 1926) seem horrifying, by revealing the nakedly experimental nature of the treatments (Pascal, Vié and Agasse, 1929). Conversely, Pascal's genial clinical account of a woman patient 'cured by joy', undergoing a spontaneous amelioration of her condition, suggested the limits of psychiatric/medical intervention (Pascal and Royer, 1935). Finally in Chagrins d'amour et psychoses (Pascal, 1935), she focused on the emotions, examining the ravages of a broken heart.

Chagrins d'amour is anything but a sentimental work. Its continuing relevance lies in Pascal's beautifully written cultural history of mental suffering in love, a condition that psychiatry as a science, she argued, had tended to avoid. Her wide, indeed omnivorous, reading permitted Pascal to range across centuries and disciplines and, among other things, to come to a nuanced, but by no means uncritical, appreciation of Freud. Her interest in Freud and his school dated from before the war. Pascal praised his insights, though dissenting from what she saw as his reductionism and pan-sexualism. She recognized that the 'talking cure' was not an option for most psychiatric patients. Nevertheless, Freud had shown the way to a semiotics that could prove the key to understanding some of the most intractable mental illnesses. I n opposition to Freud, she argued that disappointed love, when it precipitated mental breakdown, was not merely a recreation of an Oedipal moment. Like Bergson, whom she admired, she believed that we live and develop in real time. Life was more than the re-enactment of a primary experience. She linked Freud with the seventeenth-century philosopher, Blaise Pascal (no relation):

Freud had the great merit of recreating Pascal's man, he of the sick heart, the weak soul, man a slave of his instincts and lacking reason. By following the traces of love beyond the genital, he discovered the true value of the sexual aetiology of mental and physical illnesses … He merits our admiration. (Pascal, 1935: 58; original emphasis) Without being reductionist, one can suggest that in Chagrins d'amour Pascal went beyond the analysis of case-histories. She seems to have found her own voice and to have felt free to bring her philosophical and literary interests, and to some extent her personal experience, to bear on her patients' illnesses. Yet if Pascal's own perspective on disappointed love informs this text, it is, nonetheless, a surprisingly optimistic work. Love can take more than one form and can be fruitfully surmounted or sublimated. In her case, maternal love was as -if not more -profound than sexual love, which brings us back to General Mengin and Jeanne Pascal.

Family matters

Throughout Jeanne's childhood, the General was a frequent family visitor. He accompanied Constance and Jeanne on holiday and in Paris often fetched Jeanne from school (she attended the Collège Sévigné from the age of nine to seventeen). He provided some financial support. Jeanne's parents maintained a distant though cordial relationship, always addressing each other by the formal 'vous':

The General, as he was called, or Parrain (godfather), as I had been taught to call him, is associated with my first childhood memories at Charenton [Saint Maurice, 1917-19]. No doubt his role was defined by agreement with both my parents. They had no life in common. My mother lived near to or in the asylum; Parrain lodged with Colonel Baron Reille, his former Chef d'État Major. Neither the one nor the other informed their own families of the existence of their daughter. But it was quietly understood, that Parrain would help me in life. [START_REF] Mme | Recollections of Constance Pascal[END_REF] Shortly after Jeanne's fourteenth birthday (17 July 1930), her mother informed her that her adored 'Parrain' was in fact her father. The central but unspoken message that emerged from her mother's communiqué, however, was that her paternity was a secret that must never be revealed. When (26 July) the General wrote affectionate letters to Jeanne and Constance admitting paternity and pledging to do everything he could for Jeanne's welfare, he did not sign his letters. For Pascal, this sentimentality mixed with caution was characteristic of the man. She hoped that he would have formally recognized his daughter, but he did not. After the General's death, two years later, she wrote to Jeanne: 'He did not wish to do his duty towards you. He could have done so. Peace to his ashes, but a truce, too, to lies.' [START_REF] Cp | [END_REF] Madame Jeanne Rees's conclusions about her parents show her appreciation of them as actors in the social history of their time. The General, she said, had a boundless admiration for her mother and was devoted to her. But he was the prisoner of his petit bourgeois background and of the social milieu to which he had raised himself in his career. Constance Pascal had loved and admired him in 1915, but could not pardon him for not having sought to legitimize their daughter. During the General's last illness in 1932, Jeanne visited him daily in hospital, passing in the corridor elegantly dressed society ladies, strangers to her, who were part of her father's other world. At his funeral at Val de Grâce, attended by the great and the good, Constance and Jeanne Pascal were snubbed by Baron Reille, who, as a devout Catholic, once referred to Jeanne as la fille du péché (the daughter of sin). [START_REF] Mme | Recollections of Constance Pascal[END_REF] Pascal was haunted by the disadvantaged status that she and Mengin had conferred on their daughter. France -not the France of Bohemia, but of the professional middle classes -was not a country where illegitimacy was easily overlooked. Pascal knew that her distinguished public reputation would never recover from the revelation that she had born a child out of wedlock. More importantly, she knew her daughter's chances in life were compromised.

For a woman of Pascal's integrity and forthrightness, this regime of lies and deception embittered her life, especially towards the end. The most revealing document relating to the whole social/legal issue of legitimacy is an unpublished film-script she wrote about 1937 entitled 'La Goutte de Sang' (The Drop of Blood). [START_REF] Painlevé | Director of Institut de cinématographie scientifique[END_REF] Set in a research laboratory, the story concerns an eminent biologist searching for an infallible paternity test. When his laboratory assistant, a young woman Christiane Viot, finds the solution, the biologist believes that they have solved a social, not merely a scientific problem: 'Children will be sacred, they will able to have their rights by showing the proof of blood legitimacy. Faced with this proof, who will dare to renounce his child?' [START_REF][END_REF] Here was the imagined answer to General Mengin's pusillanimity. In a country where women still had few civil rights, a child's legal identity was vested in the father. Proof of paternity was in a sense proof of existence. However, as the drama unfolds, other points of view emerge. One researcher doubts that anything will change; his professor's faith in social transformation through science will run up against masculine intransigence: 'He doesn't take into account men's cowardice … and that since the world is as it is, the male governs everything'. 5 1 Christiane (the unacknowledged and unknown daughter of the eminent biologist) becomes disillusioned with the social results of her discovery. She attacks the biologist for his success in implementing systems to track down errant fathers:

The new man that you have created is ridiculous, abnormal, pathetic. He is perpetually hounded. Marriage is no more than a prison where the parents are obliged to obey the law of blood ties … even if they detest each other; they live like chained convicts with their unhappy children. Ah! Science, don't you see, can't create morality; it lacks pity, it only has one aim: cold truth and glacial justice. It dries up the generous impulses of nature … Its rigid formulas are inapplicable to morality. 52 Pascal, in imagining a solution to the problem of acknowledging paternity, concluded that moral dilemmas will always be with us. The religion of science to which she had dedicated her life, was insufficient. Her protagonist affirms a virtually Kantian ethical imperative in the declaration: 'No one is allowed to live without some constraint. No one is moral enough to merit complete liberty.' 53

Conclusion

Pascal was driven by an ethical passion devoid of any religious basis. Although she sought truth through science, she looked increasingly to philosophy, literature and social action for meaning. Probably to this end, she subscribed to l'Union pour la vérité, a journal of the left, concerned with the restoration of moral values and workers' education (Chaubet, 2000). Her social concerns were reflected in her pioneering work in the education of children with severe learning difficulties which deserves far more recognition than it has received. Looking back over her career, she was justifiably proud of her role in advancing the cause of women in psychiatry and in improvements that she had championed in psychiatric care. Her daughter's academic success delighted her, though she did not live to see her pass her agrégation, or her marriage to the young Welshman who in 1930 had been employed to tutor Jeanne in English. In the last year of her life, Pascal was still working on a major new project, a monograph to be entitled La Démence précoce de Morel-Kraepelin et le problème de la schizophrénie. 5 4 She died of cancer on 21 December 1937, at her house at Maison Blanche, alone except for her daughter and medical attendants. Stoical in the face of death, she had insisted on the simplest of funerals and wanted no commemoration in the psychiatric press. Dr Jacques Vié, who wrote her obituary, provided the only official notice of her death (Vié, 1938).

Pascal's work in psychiatry is notable for its evolution and its lack of dogmatism. Her empathy with her patients arose from clinical observation, from her own emotional scars and her wide cultural perspective:

The person wounded by love is someone with a hyper-affective memory; his recall of painful emotions is over-developed. 'He suffers because he remembers' (Beethoven). Time, as he lives it painfully, is continually regained. This constitutes the essential framework of the sorrows of love. To the distressing burden of the past is added the harrowing burden of the present. Proust rediscovered his lost Eden, whereas the person wounded by love keeps rehearsing his despair, and allows himself to be obsessed by disgust or hatred. (Pascal, 1935: 159) It is not an ad feminam argument to suggest that Pascal's own deception in love contributed to her interest in and concern for those 'blessées d'amour' who, unlike herself, had lacked the intellectual and emotional strength to overcome their despair. The fact that the majority of clinical examples in Chagrins d'amour are women points to her conviction that many of the emotional disasters in life fell disproportionately on women; they were the distorted mirror of social realities underpinned by masculine power structures.

Constance Pascal's virtual disappearance from the historical record until recently was partly self-imposed and partly due to newer fashions in psychiatry that eclipsed her work, especially on dementia praecox. Feminist historians have also failed to give her the attention she merited, because of the technical nature of her writing and because it was wrongly assumed that her much extolled feminine persona precluded a feminist commitment. Her gushing journalistic admirers, focusing on her personal appearance, served her badly with subsequent scholars, as in this extract (Anon., 1905): She is a foreigner, like many women doctors: a Romanian. Her great black eyes bring to mind her country of origin … She always dresses in black, which suits her. As for her hair, a carefully arranged chignon and two neat coils over the temples, demonstrate that a certain 'coquetry' and aesthetic sense are not incompatible with science.

It may be thought that Pascal paid a heavy price for her professional distinction in terms of the burdens it placed on her. But she succeeded in balancing her two worlds: in maintaining her economic independence and in raising her daughter to compete in the hot-house of French intellectual life. She was not a victim. When faced with certain death, she expressed anguish, but also demonstrated great courage. She kept her secret to the end. The product of a Francophone, pan-European culture as it existed before World War I, Constance Pascal was a remarkable example of those gifted and dedicated new women determined to prove their absolute competence in a man's world.

FIG. 1 .

 1 FIG. 1. Constance Pascal as a young woman, c. 1905 (source: La Vie heureuse, 1905)

FIG. 3 .

 3 FIG. 3. Jeanne Pascal's birth certificate, 1916 (source: PRFP)

Acknowledgements

I wish to thank Anglia Polytechnic University, the British Academy and The Wellcome Trust for grants in support of this project. I am most grateful to Mme Jeanne Rees and Dr Margaret Rees for access to the Pascal/Rees Family Papers.