The real Sylvia Plath

Her newly published, unexpurgated journals support a little-known theory that PMS drove her to suicide. Second of two parts.

Topics: Books,

The real Sylvia Plath

As a teenager, Sylvia Plath vividly understood the extent to which her body steered her. “If I didn’t have sex organs, I wouldn’t waver on the brink of nervous emotion and tears all the time,” she wrote in her journal in 1950. Ten days before her death, she had come to believe that “fixed stars/Govern a life.” It turns out that Plath was probably right — more right than she could have possibly known — about her biology and her fate. But when Plath’s journals were first published in 1982, what was most obvious about her was the supercharged nature of her emotions. Whatever causal agents may have been governing Plath’s life, they were blown back by the force of her personality.

As unmistakable as were Plath’s volatile emotions in the 1982 journals, the heavy editing of the text necessarily made it hard to discern the patterns to her moods. Even so, there did seem to be a detectable pattern, and it did not seem then, nor had it seemed to the people closest to her during the last years of her life, to be merely a function of temperament. In the weeks before her suicide, Plath’s physician, John Horder, noted that Plath was not simply deeply depressed, but that her condition extended beyond the boundaries of a psychological explanation.

In a letter years later to Plath biographer Linda Wagner-Martin, Horder stated: “I believe … she was liable to large swings of mood, but so excessive that a doctor inevitably thinks in terms of brain chemistry. This does not reduce the concurrent importance of marriage break-up or of exhaustion after a period of unusual artistic activity or from recent infectious illness or from the difficulties of being a responsible, practical mother. The full explanation has to take all these factors into account and more. But the irrational compulsion to end it makes me think that the body was governing the mind.”

For at least the past 10 years it has been generally assumed that Plath fit the schema of manic-depressive illness, with alternating periods of depression and more productive and elated episodes. In the epic 1990 textbook “Manic Depressive Illness” by Frederick K. Goodwin and Kay Redfield Jamison, Plath is footnoted in a table listing major 20th century poets with documented histories of manic-depressive illness. Though Plath was never treated for episodes of mania, the authors concur that she would probably have been diagnosable with bipolar II, one of the two types of manic-depressive illness.



The description in the first paragraph of the book sounds strikingly like Plath: “Manic-depressive illness magnifies common human experiences to larger-than-life proportions. Among its symptoms are exaggerations of normal sadness and fatigue, joy and exuberance, sensuality and sexuality, irritability and rage, energy and creativity … To those afflicted, it can be so painful that suicide seems the only means of escape; one of every four or five untreated manic-depressive individuals actually does commit suicide.” Dr. Jamison, a leading expert in the field of affective illness, also includes Plath in her 1993 book, “Touched With Fire: Manic-Depressive Illness and the Artistic Temperament.”

The hypothesis that Plath suffered from a bipolar disorder is persuasive. But in late 1990, another, even more intriguing medical theory emerged. Using the evidence of Plath’s letters, poems, biographies and the 1982 journals, a graduate student named Catherine Thompson proposed that Plath had suffered from a severe case of premenstrual syndrome. In “Dawn Poems in Blood: Sylvia Plath and PMS,” which appeared in the literary magazine Triquarterly, Thompson theorized that Plath’s mood volatility, depressions, many chronic ailments and ultimately her suicide were traceable to the poet’s menstrual cycles and the hormonal disruptions caused by PMS.

“Accurate medical knowledge of PMS has become available in the United States only in the last ten years, and Plath herself could not have known that her psychological experience was a result of a hormonal condition,” Thompson wrote. “Yet the concerns of her work and the imagery of her poems suggest that she did have at least an intuitive understanding of the relationship between her fertility and her suffering.”

In addition to cycles of death and rebirth and the motif of true and false selves, the major recurring themes to be found in Plath’s self-reflective and ritualized poetic mythology are those of female fertility and power, and the controlling force of a feminine moon goddess. Thompson cited extensive medical research, including that of pioneering PMS researcher Katharina Dalton, to corroborate the results of her examination of Plath’s symptoms in relationship to cyclic hormonal changes in PMS sufferers. She argued that some of Plath’s poems, in particular those of the “Ariel” period, were not just figurative, abstract expressions of Plath’s preoccupation with female fertility, but were directly correlated with Plath’s biology. “Metaphors for ovulation and menstrual blood are prevalent in her late work,” noted Thompson, “and the thematic oscillation from suffering to rebirth in these poems appears to follow the phases of Plath’s own menstrual cycle.”

The proposal that an important poet’s works were significantly influenced by PMS is likely to exercise a number of people, for quite different reasons. Aesthetic purists tend to attack all such biological-influence theories as reductive, while others dispute the scope — and even the existence — of PMS itself. Heated controversies continue to rage around PMS: whether it is a medical condition or a psychological one, whether its cause is a lack of progesterone or an inability to metabolize fatty acids, whether it is an admissible tool for legal defense or an excuse for criminal conduct, whether it is treatable by hormone therapy, Prozac or liberal doses of St. John’s Wort, whether it is a step forward in understanding women’s health or a politically retrograde tool for shoring up tiresome gender stereotypes.

While the controversy rages, the medical establishment has accepted PMS as a bona fide condition. According to the most current clinical handbook of psychiatric diagnoses, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV, published by the American Psychiatric Association in 1994), “at least 75 percent of women report minor or isolated premenstrual changes.” The DSM-IV estimates that 20 to 50 percent of menstruating women suffer from some form of PMS (other sources put the number as high as 75 percent), while 3 to 5 percent of women are estimated to suffer from the most severe form of PMS, PMDD, or premenstrual dysphoric disorder.

Symptoms are considered premenstrual if they appear during the luteal phase of the cycle (the 14 days between ovulation and menstrual flow), begin to remit within a few days of menses and are totally absent in the week following menses. To meet the diagnostic criteria for PMDD, a woman must have at least one severe emotional (as opposed to physical) symptom each month, the severity of which must be great enough to have a major negative impact on normal functioning.

Thompson pointed out that Plath unwittingly recorded experiencing on a cyclical basis all of the major symptoms of PMS, as well as many others, including low impulse control, extreme anger, unexplained crying and hypersensitivity. She also suffered many of the physical symptoms associated with PMS, notably extreme fatigue, insomnia and hypersomnia, extreme changes in appetite, itchiness, conjunctivitis, ringing in the ears, feelings of suffocation, headaches, heart palpitations and the exacerbation of chronic conditions such as her famous sinus infections.

Thompson compared Plath’s reported mood and health changes with the journals, letters and biographies and found that her symptoms seemed to appear and disappear abruptly on a fairly regular schedule, with clusters of physical symptoms and depressive affect followed by dramatic changes in outlook and overall physical health. Those patterns can be directly linked to the dates of Plath’s actual menses, particularly in 1958 and 1959, when she most habitually noted her cycles. Judging from the pattern of Plath’s depression and health in late 1952 and in 1953 until her Aug. 24 suicide attempt, Thompson posited that “it seems reasonable to conclude that this suicide attempt was directly precipitated by hormonal disruption during the late luteal phase of her menstrual cycle and secondarily by her loss of self-esteem at being unable to control her depression.”

Thompson showed that a well-known journal entry from Feb. 20, 1956, is clearly traceable to Plath’s menses, to which she refers directly a few days later. The journal fragment takes on new meaning in light of having been written during the physically and emotionally debilitating luteal phase of Plath’s cycle: “Dear Doctor: I am feeling very sick. I have a heart in my stomach which throbs and mocks. Suddenly the simple rituals of the day balk like a stubborn horse. It gets impossible to look people in the eye: corruption may break out again? Who knows. Small talk becomes desperate. Hostility grows, too. That dangerous, deadly venom which comes from a sick heart. Sick mind, too.” On Feb. 24, the same day she notes in her journal that she has a sinus cold and “atop of this, through the hellish sleepless night of feverish sniffling and tossing, the macabre cramps of my period (curse, yes) and the wet, messy spurt of blood,” Plath wrote a letter to her mother blaming her dark mood on her physical health: “I am so sick of having a cold every month; like this time, it generally combines with my period.”

By perhaps fateful coincidence, Plath’s Feb. 24, 1956, period is the first she mentions specifically in her entire journal; the next day, she met her future husband, Ted Hughes, at a party. Thompson explains that disruptions in the menstrual cycle, particularly those caused by pregnancy and breast-feeding, can have a dramatic hormonal impact on PMS sufferers; in the two and a half years between June 1959 and January 1962, Plath experienced three pregnancies, one of which ended in miscarriage. In addition, she breast-fed both of her babies for lengthy periods (10 months for Frieda, about eight months for Nick, according to letters to her mother) and probably experienced very few normal menstrual cycles during that time.

Wrote Thompson, “Her reproductive history almost guaranteed some form of extreme emotional disruption once she began menstruating again after the birth of her second child, with a probable further disruption following the cessation of breastfeeding. Like many women with PMS, Plath seems to have experienced relief from cyclical symptoms during the last two trimesters of pregnancy and to have suffered from lengthy postpartum depressions.” That last disruption, in the fall of 1962 when she weaned Nicholas, would have coincided with the writing of the “Ariel” poems.

Thompson’s close reading of the “Ariel” poems in terms of Plath’s menses noted the discernibly cyclic pattern of rise and fall in mood and tone in the poems as well as their many images and themes of barrenness, fertility, psychic pain, bleeding and relief, always controlled by the overseeing influence of the inspiring but uncaring and all-powerful moon goddess. “If I could bleed, or sleep!” Plath wrote in “Poppies in July,” shortly after the discovery of her husband’s adultery in July 1962, presumably a time when Plath was not just emotionally distraught but also experiencing suppressed menstruation because of her young baby’s breast-feeding.

By the fall of 1962, the poems (which Plath carefully dated as they were completed) seem to follow a pattern of metaphorical renewals and optimistic transformations for roughly two to three weeks of artistic production, then jagged, seething accusations and aggression for a couple of weeks. (As can be seen in the unabridged journals, for at least two years prior to the beginning of her first pregnancy in 1959, Plath’s menstrual cycles had regulated to cycles of 30 to 35 days, which corresponds with the timing of the “cycles” of the Ariel poems.)

Thompson’s article closes on a note of tragic irony: Dalton, who had coined the term “premenstrual tension” in 1954 and who was the only physician successfully treating women for severe PMS in 1963, practiced in London. Plath, who had moved to London from her country home in December 1962, “died in the only city in the world where she could have received effective medical treatment.”

Thompson’s PMS theory has been largely ignored by Plath scholars. But it immediately gained two important supporters: Anne Stevenson, Plath’s controversial biographer, and Olwyn Hughes, Plath’s former sister-in-law, whose letters were published in a subsequent issue of Triquarterly. Though oddly defensive in tone, Stevenson’s letter does commend Thompson for her “invaluable contribution to Plath scholarship … Certainly no future study of Plath will be able to ignore the probable effects of premenstrual syndrome on her imagination and behavior.” And it states that she wishes she had been able to utilize Thompson’s insights in the writing of her own work on Plath.

A letter from Olwyn Hughes also congratulates Thompson for her scholarship, but unlike Stevenson, Hughes practically stumbles over herself in amazement at the PMS theory. Hughes, who was quoted in Janet Malcolm’s book “The Silent Woman: Sylvia Plath and Ted Hughes” as characterizing her long-dead sister-in-law as “pretty straight poison,” wrote to Thompson: “It is quite a shock to digest all this — after thinking for so long that Sylvia’s subconscious mind was her prison, and to suddenly realise it may well have been in part, or wholly, her body. But it certainly tallies with Ted’s mentions — he has always felt some chemical imbalance was involved.”

Hughes further points out that Ted Hughes had spoken of Plath’s ravenous appetite just prior to her periods and asks, “I wonder if that is a known characteristic of PMS?” (According to the PMS literature, it is.) But most tellingly, Olwyn Hughes explains that “one of the reasons I was so bowled over by your piece is that Sylvia’s daughter, very like her physically, suffers quite badly from PMS but is, in these enlightened times, aware of it and treats it.”

Dr. Glenn Bair, one of the leading experts on PMS treatment and research in the United States, confirmed to Salon that PMS is typically passed from mother to daughter. In a rare interview about her parents, Frieda Hughes told the Manchester Guardian in 1997 that after the “collapse of her health,” including extreme fatigue and gynecological problems, she underwent a hysterectomy in her 30s.

Salon recently contacted Dalton, who had just retired from medical practice in London after 52 years. In that interview Dalton revealed for the first time that in early 1963 she had, in fact, been contacted by Horder to set up a consultation with Plath. According to the Plath biographies by Stevenson and Wagner-Martin, Plath only revealed her psychiatric history and the extreme nature of her current depression to Horder in late January 1963.

“John Horder and I had known each other for some time,” Dalton said. “He was fully aware of my work and was with me the first time I ever spoke in public about premenstrual syndrome in 1954, at the Royal Society of Medicine. We were on the Council of General Practice together for 25 years.” After calling her regarding his patient Plath, Dalton says that Horder “referred her to me. You don’t have to tell me about Sylvia Plath. I was to see her, but she had killed herself before I could.” After reviewing the information in Thompson’s article and asked her opinion of the possibility that Plath may have suffered from PMS, Dalton said, “There is quite a lot of evidence. Oh yes, I think she had it. But the only one who really did understand [Plath] was John Horder. That’s why he had called me.”

Both Wagner-Martin and Stevenson, as well as several other Plath biographers, have written that Horder set up an appointment for Plath with a female doctor, sometimes referred to as a psychiatrist, in the last few days of her life. Plath refers to her plan to see a female doctor in a letter written a week before her death. Whether Horder had contacted both a psychiatrist and Dalton is unknown; when reached for comment, Horder declined further statement on Plath’s death, citing his decision several years ago to say nothing more and expressing his lingering regret at what he considers his “breach of confidentiality” when he spoke publicly of Plath on an earlier occasion.

Bair, who has studied with Dalton, gave his opinion about Horder’s decision to contact a PMS specialist when Plath was in an acute state of distress. “You have to consider this about John Horder. He was very well connected,” said Bair. (Horder is the highly respected former president of the Royal College of General Practitioners in London.) “He most likely had access to 500 psychiatrists and 1,000 other specialists. The odds of him picking Dalton are very small — but you don’t send a patient to a colleague without having a strong belief that their specialty will help that patient. For one minor point, doctors don’t have the time to take blind referrals for patients not applicable to their specialty. Neither do the patients — especially patients in dire need of help.”

After a careful review of Thompson’s article, of a seven-page monthly breakdown of Plath’s symptoms for 1958 through 1959 and of the documented evidence of Plath’s pregnancies and postpartum symptoms of 1959 through 1962, Bair said, “If you hack through the PMDD criteria, I think that you’ll find that she fits the PMDD profile.”

With the publication of the unabridged journals, even more of Plath’s biographical record can be assessed in light of Thompson’s PMS theory. The more thorough and accurate dating of entries in journals for 1958 and 1959 in particular fleshes out the prevalence and patterning of Plath’s numerous references to her physical symptoms and feelings. Among the dozens of Plath’s commentaries that appear to be unique to the luteal phase of her cycles are these: “Am I living half alive?” “A peculiar hunger and thirst upon me.” “I have an ominously red, sore & swollen eyelid, a queer red spot on my lip — and this enervating fatigue like a secret and destructive fever.” “My eyelid’s hot stinging itch has spread … to all my body: scalp, leg, stomach: as if an itch, infectious, lit and burned, lit and burned. I feel like scratching my skin off. And a dull torpor shutting me in my own prison of highstrung depression … I feel about to break out in leprosy … my eyes are killing me — what is wrong with them.”

The notorious 1958 incident with Hughes and a female university student on Plath’s last day of teaching took place, as Thompson had earlier suggested and the unabridged journals now confirm, during the luteal phase of Plath’s cycle; so did the memorable “button quarrel” between Plath and Hughes. Plath’s “unexplained” fevers, which would recur and become immortalized in the “Ariel” period, are recorded exclusively in the luteal phase of her cycles, as are a vast majority of her chronic sinus troubles. Using both the unabridged journals to assess cyclical patterning and Plath’s calendars from 1952 and 1953 (housed in the University of Indiana’s Lilly Library), in which Plath recorded her periods through July 1953, it seems overwhelmingly likely that Plath was, as Thompson contended, in either the luteal or the perimenstrual phase of her menses at the time of her 1953 suicide attempt.

Even incidents that occurred during the time covered by destroyed or lost journals can be illuminated by Thompson’s PMS theory, coupled with outside documentary evidence. For example, the due dates of Plath’s second and third pregnancies and her weaning schedule for Frieda in 1960, all noted in her letters, clarify that three of Plath’s most disastrous episodes of violent or antisocial behavior occurred during the luteal phase of her cycles, which was made even more acute by pregnancy.

Plath’s December 1960 argument with Olwyn in Yorkshire, after which the sisters-in-law never saw each other again, took place when Plath was newly pregnant for the second time but in what was hormonally the late luteal phase of her cycle. One month later, in an irrational fit of jealous rage, Plath destroyed her husband’s most precious possession, his leatherbound copy of the Oxford Collected Shakespeare, as well as all of his papers and works in draft on his desk; a few days later, Plath miscarried. (Miscarriage is also considered a fairly common symptom of severe PMS.)

Five months later, now pregnant for the third time, Plath wreaked chaos during a vacation to France at the summer home of poet W.S. Merwin and his wife, Dido, a holiday from hell recounted with indelible animus by Dido Merwin in Stevenson’s Plath biography. Again, the trip’s date places Plath in the late luteal phase of her cycle.

The unabridged journals reveal that on March 20, 1959, Plath’s psychoanalyst told her that “cramps are all mental after arguing against natural childbirth, saying pain was real,” which could only have served to increase Plath’s inability to connect her symptoms to a cause that was beyond her control. Though Plath’s cramps and many more of her symptoms were physically, palpably expressed, their impact on her interior, “mental” life was equally real. Plath endlessly noted her agonizing symptoms, castigated herself for her inability to gain control over her life, even dreamed frequently about her periods, and yet could not make the connection between her cycles of fertility and cycles of torment.

“Yesterday was a horror,” Plath wrote during the luteal phase of her cycle in March 1958. “Ted said something about the moon and Saturn to explain the curse which strung me tight as a wire and twanged unmercifully.” A month later, Plath describes a nightmare in which she watches a “diamond moon” passing by before she becomes a moon herself: “I was lifted, up, my stomach & face toward earth, as if hung perpendicular in mid-air of a room with a pole through my middle & someone twirling me about on it … & my whole equilibrium went off, giddy, as I spun & they spun below & I heard surgical, distant, stellar voices discussing me & my experimental predicament & planning what to do next.”

Plath’s journal is crowded with references to the moon, which notably worked itself into her poetry; a journal entry from 1950 that had appeared in the 1982 edition takes on even greater metaphoric meaning in light of the PMS theory:

Tonight I wanted to step outside for a few moments before going to bed, it was so snug and stale-aired in the house. I was in my pajamas, my freshly washed hair up on curlers. So I tried to open the front door. The lock snapped as I turned it; I tried the handle. The door wouldn’t open. Annoyed, I turned the handle the other way. No response. I twisted the lock … still the door was stuck, white, blank and enigmatic. I glanced up. Through the glass square, high in the door, I saw a block of sky, pierced by the sharp black points of the pines across the street. And there was the moon, almost full, luminous and yellow, behind the trees. I felt suddenly breathless, stifled. I was trapped, with the tantalizing little square of night above me, and the warm, feminine atmosphere of the house enveloping me in its thick, feathery smothering embrace.

The unabridged journals now date Plath’s writing of “Moonrise,” a poem metaphorically meditating on the “boney mother” moon and hopes of pregnancy (“The berries purple/and bleed. The white stomach may ripen yet”), as having been written in Plath’s luteal phase. The poem “Metaphors” — the metaphors being those for pregnancy — was completed on March 20, 1959, in the perimenstrual phase, presumably begun when Plath still thought she might be pregnant. (“March 20, Friday. Yesterday a nadir of sorts … Pregnant, I thought. No such luck.”)

Another poem, “A Life,” in which a woman drags her shadow around the moon but has been exorcised of “grief and anger,” was completed on Nov. 18, 1960, and so was written during the week in which Plath (according to the dates she gave her mother) must have ovulated and become pregnant for the second time. Because Plath’s subject matter in these poems is so blatantly and directly linked to the phase of her menstrual cycle at the time the poems were written, their specific dating and the circumstances of their production give more credence to Thompson’s conclusions about Plath’s menstrual cycles affecting the creation of poems during the “Ariel” period, for which there is no dated evidence of menstrual cycles.

The unabridged journals reveal some problems with Thompson’s theory, but they are mostly minor dating mistakes that don’t ultimately undermine her findings. The more important point made evident by the unabridged journals is that Plath’s mood swings did not run on as predictable a schedule as Thompson assumed. Though Plath’s physical symptoms evaporate almost miraculously with the onset of her periods, her emotional turmoil remains unpredictable throughout the month. The diagnostic definitions for PMS and PMDD state that symptoms “are always absent in the week after menses”; however, Bair has noticed in his clinical practice that with PMS, depression “is the slowest symptom to clear, and in fact seems to build up over time,” coupled with the decline of a woman’s self-esteem as she finds herself unable to control her emotions. Several studies on PMS corroborate Bair’s observations.

The years for which we have the most consistent and detailed menstrual data for Plath, 1958 and 1959, are unfortunately years in which Plath was also sunk in a long-term depression over her teaching job and her consequent writer’s block. It is, then, almost impossible to sort Plath’s emotional responses to potential PMS from her ongoing depression.

The years 1952 and 1953, two years for which we also have accurate dating of Plath’s menses, are years in which Plath’s emotional life is far more varied and the trajectory of her deepening depression is easier to detect; and yet even during these early years Plath’s moods do not consistently correspond to her cycles in a way that points unquestionably at PMS. It may be, as is often the case with PMS sufferers, that Plath’s PMS worsened as she grew older; it may also be that something else was at work in Plath’s biological war with her selves.

There is a striking overlap and similarity between the symptoms of severe PMS and the depressive phase of bipolar II that apply in Plath’s case: insomnia and hypersomnia, appetite changes, low impulse control and irritability, mood lability, restlessness and anxiety, fatigue and lethargy, feelings of inadequacy and magnified guilt, and suicidal thoughts and action. Since a diagnosis of bipolar II fits Plath’s behavioral and hereditary profile without explaining her cyclical physical symptoms or her artistic preoccupation with her fertility, while PMS does not fully account for Plath’s overall fluctuation of moods and her hypomanic states, it seems reasonable to hypothesize that Plath may have suffered from both bipolar II disorder and a severe case of PMS.

Medical and psychiatric researchers have been investigating connections between affective illnesses and menstruation in recent years, particularly the overlapping nature of symptoms for PMS and mood disorders as well as the co-morbidity of the illnesses (the number and likelihood of women having both illnesses at once, as well as how the illnesses affect each other). The PMDD criteria of the DSM-IV state that women with recurrent major depressive disorder (MDD), bipolar I or bipolar II or even a family history of such disorders may be at greater risk for PMDD.

Other findings are that women with MDD or rapid-cycling bipolar disorder commonly experience “premenstrual exacerbation” of their mood symptoms; that PMS may trigger affective episodes and that PMS is possibly a unique form of affective disorder; that women with past or current psychiatric illness, principally affective disorders, report a higher incidence of PMS than normal controls; that PMS is not simply always a premenstrual worsening of affective illness but has validity independent of other affective syndromes; that there tends to be a cycle-to-cycle worsening of premenstrual symptoms and depression prior to prolonged episodes of MDD; that women with postpartum depression are more likely to develop premenstrual depressions several months after the resumption of menses; that some women may have a biological vulnerability for mood disorders that is “triggered” by menstrual changes; and that the relationship between PMS and bipolar illness does not always stay static over a woman’s lifetime. The cycles do not necessarily coincide, and in some phases the woman may have “pure” PMS/PMDD while at other times she has premenstrual worsening of her mood disorder.

One of the most disturbing similarities between bipolar II and severe PMS is the potentially lethal nature of both illnesses. Goodwin and Jamison’s “Manic Depressive Illness” reports that “patients with depressive and manic-depressive illnesses are far more likely to commit suicide than individuals in any other psychiatric or medical risk group.” The suicide statistics on PMS sufferers are equally catastrophic. Some studies have shown that up to one-third of severe PMS sufferers have attempted suicide. According to a 1993 study called “The Menstrual Cycle and Mood Disorders” by Dr. Jean Endicott of the New York State Psychiatric Institute, there is evidence that suicide attempts are more likely during the premenstrual phase of the cycle, and “there is evidence from autopsies that completed suicide is more likely to occur during the late luteal phase of the cycle.”

Another study, “Premenstrual Tension Syndrome in Rapid-Cycling Bipolar Affective Disorder” by William A. Price and Lynn DiMarzio, notes that “the paramenstruum, the 4 days preceding and the first 4 days of menstruation, is associated with increased rates of medical, surgical, and psychiatric hospitalizations; increased rates of suicide attempts; and increased severity of suicidal intent.” These findings support those of Dalton, whose studies of British women have shown that suicide attempts increase 17-fold during the luteal phase as opposed to the preovulatory phase of the cycle.

Though scientific researchers have noted that there is a relationship between bipolar illness and PMS, they have not yet clarified the parameters of that relationship. Nevertheless, it can be cautiously concluded that Plath suffered from some degree of both affective and premenstrual illness, even if how those two illnesses may have corresponded is impossible to detect.

Why does it matter? Why try to understand who Plath was beyond what rises immediately to the surface in her poetry? Perhaps the answer lies first with Plath’s ceaseless desire to understand the dendritic and operatic machinations of her psyche, her “million filaments,” and how that quest for self became not just the driving force behind her creativity but also the undeniable key to the richly textured artistry it produced.

Plath was ultimately as much an enigma to herself as she is now to us. During the weeks before her death she was fervently engaged in putting together the puzzle of her “Ariel” poems, giving them a logical sequence, a narrative cohesion that amounted to a mythic performative utterance. She was putting them in an order that would tell her the story of her own survival, her phoenixlike eruption from the ashes of her destroyed marriage and the shed skin of her “false” selves.

“Will the hive survive, will the gladiolas/Succeed in banking their fires/To enter another year?” she had asked herself in “Wintering,” the poem, almost a prayer, that she chose to end her “Ariel” manuscript in December 1962. “The bees are flying,” the poem concludes. “They taste the spring.” Plath wanted to know that she would survive that English winter; she willed herself, as she had done countless times before, toward the spring of her inner life.

Understanding Plath’s biology underscores her very human, as opposed to iconic, instinct toward self-preservation. If one accepts the possibility that Plath’s true demon was not something of her own making but a force, or forces, she was quite powerless against, her attempts to juggle the details of her daily life, to care for herself and her small children alone and furthermore to programmatically write “dawn poems in blood” to save her sanity seem nothing less than courageous.

It also hints at the possibility that Plath’s notable premonitory abilities (verging on telepathy), her seemingly numinous sensitivity, may have arisen in some part from a subconscious understanding that her psychological suffering was also the source, in a very material way, of her internal artistic fire — the fire that would finally burn hot enough to work the alchemical change that Hughes described.

What is breathtaking about the possibility that Plath may have suffered both bipolar II and PMS is that in tandem, those two illnesses totally integrate her daily and imaginative life, her artistic fascinations and her emotional despair, her life as a woman and as a writer, and they do so without diminishing Plath’s achievement in any way. Her ars poetica, not just brilliantly executed but brilliantly won despite unbelievable odds, leaps into focus in even more astonishing detail than ever before.

As Jamison remarks of mystic poet William Blake in “Touched With Fire,” “suggesting the diagnosis of manic-depressive illness for Blake does not detract from the complexity of his life; it may, however, add a different kind of understanding to it. Likewise, it does not render his work any the less extraordinary, or make him any less a great visionary or prophet. [The diagnosis] may not explain all or even most of who he was. But, surely, it does explain some.”

In Plath’s case, the conjectural diagnosis of manic-depression and PMS may explain almost everything. And it only makes more miraculous what Hughes once described as “the truly miraculous thing about her,” a thing he directly attributed to Plath’s fertility, an event precipitated by the births of her two children: “In two years, while she was almost fully occupied with children and house-keeping, she underwent a poetic development that has hardly any equal on record, for suddenness and completeness … All the various voices of her gift came together, and for about six months, up to a day or two before her death, she wrote with the full power and music of her extraordinary nature.”

In a stunning turnabout, her devastating illnesses may not have just inspired Plath but also enhanced her ability to apprehend her material and shape it. Plath’s subterranean connection to her female biology seems to have been aligned with the expansive flourish of hypomania’s supple thinking, its flights back into the caves and coves of the mind. While she was writing the poems of “Ariel” in the fall of 1962, being “pulled through the intestine of God,” as she called it in a letter, she was also carefully correcting the galleys for “The Bell Jar” — in other words, she was engaged in both a creative act requiring the limitless probing of psychic depths and the organizational feat of logic and objectivity demanded by editing.

When one considers the precision and feverish grace of Plath’s last six months of writing, it is impossible to imagine her as anything but utterly in control of that gift. One might say that Plath was able, for a finite and delicately balanced period, to use her illnesses to keen artistic advantage. “I feel like a highly efficient tool, or weapon,” Plath marveled that fall.

Plath’s fertility, to which she may have gained greater figurative access through bipolar illness, then became both her darkness and her glory — her artistic salvation and her downfall, a double-faced gift she thematized, whether consciously or unconsciously, in her poetry. No one has ever written more uncannily of motherhood than Plath, or captured so perceptively the shock of maternal otherness — its frightening and awesome complexity and distance, feelings as genuine and “normal” as love and connection.

Plath understood and experienced motherhood as “much deeper, much closer to the bone” than love or marriage, and yet her hypersensitive awareness of what is closest to the bone — the aspect of motherhood that is subjective and strange and dictated by blood — taps into a vein of truth not easily embraced by the usual exalted sentiments. “I’m no more your mother,” Plath wrote, “than the cloud that distills a mirror to reflect its own slow/Effacement at the wind’s hand.” This recurring maternal imagery of chthonic separation, apparent even to a casual reader of Plath, is a clear manifestation, at some level, of the mixed blessing of Plath’s female body. It is also why so many critics have accused her of ambivalence toward motherhood — a crude misapprehension of Plath’s anguished and profound relationship to her own fertility.

Ultimately, the foremost reason to try to understand Plath is that it leads us unfailingly back to her poems, the work she knew qualified her as “a genius of a writer.” As insulated against easy access as Plath’s poetry remains, it is astounding to note how many passionately moved readers she has won over 40 years, and how often women, in particular, will say that they first read her in school, perhaps voyeuristically, and later came to “understand” her and value her writing on a deeply intuitive level only after marriage and children. Her poems continue to reward reading after reading, year after year; they remain as multifaceted, mysterious and bristling with life as the enigma of their creator, who was in her deepest being a woman, a mother and an artist.

“They saved me,” Plath told Hughes in December 1962, speaking of the fury and agony she poured into “Ariel.” “One can see a great revival of spirits in her letters,” Hughes wrote many years later to Aurelia Plath of those bleak months after Plath and Hughes split up, Plath insisting that she would settle for nothing other than a divorce. “And that was the front she presented to me at the time,” Hughes continued. “But as I’ve said it was only in that last week that her front crumpled and I realised the whole thing was a bluff. But then she was going off for the weekend and Monday morning was too late.”

When she wrote her last letter to her mother, Plath was on antidepressants, and Horder, who was scrambling to get her a hospital bed, was calling or seeing her daily. Plath’s friends in London have reported that she seemed distraught and desperate and was so distracted that she could no longer care for her children’s daily needs. On Feb. 4, 1963, one week before her death, Plath wrote reassuringly to Aurelia, “I am going to start seeing a woman doctor, free on the National Health, to whom I’ve been referred by my very good local doctor, which should help me weather this difficult time.”

On Feb. 7, she wrote with brisk efficiency to friends in Devon that she was coming back. (“I long to see my home,” she said.) Between those letters, Plath composed her final poem, “Edge,” in which the unmoved moon observes the “perfected” body of a dead woman:

The moon has nothing to be sad about,

Staring from her hood of bone.

She is used to this sort of thing.

Her blacks crackle and drag.

To the very end Sylvia Plath hid behind her masks, pulling her veils around her even into death. One can only wonder who, that last winter Monday, she thought she was then.

Kate Moses is the author of "Wintering: A Novel of Sylvia Plath" (St. Martin's.) She was the co-founder, with Camille Peri, of Salon's "Mothers Who Think" site, and she and Peri also co-edited the award-winning book "Mothers Who Think: Tales of Real-Life Parenting." She lives in San Francisco.

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