From Paralysis to Fatigue

A History of Psychosomatic Illness in the Modern Era

Edward Shorter

• Publisher: Free Press
• Year: 2008
• ISBN:
  9781439105641
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The first book to put the physical symptoms of stress in their historical and cultural context. This fascinating history of psychosomatic disorders shows how patients throughout the centuries have produced symptoms in tandem with the cultural shifts of the larger society. Newly popularized diseases such as "chronic fatigue syndrome" and "total allergy syndrome" are only the most recent examples of patients complaining of ailments that express the truths about the culture in which they live.

CHAPTER 1

Doctors and Patients at the Outset

The descent from mind to body is a tricky one. How does the mind, interpret the signals the body gives off? A young executive feels a stomachache before an important presentation. There is nothing physically wrong with her stomach. In the absence of any physical lesion, her mind perceives pain coming from the stomach. That pain is psychogenic, unlike the pain of a gastric ulcer, which is somatogenic. (Somatogenic means there is something physically wrong with the body, and damaged nerve endings are causing the pain.)

Do psychogenic symptoms have a history of their own? Have they perhaps always been more or less the same, as coughing up sputum, if one has pneumonia, has historically been invariant? One factor that confers a history is the doctor’s attitude. Patients want to please doctors, in the sense that they do not want the doctor to laugh at them and dismiss their plight as imaginary. Thus they strive to produce symptoms the doctor will recognize. As doctors’ own ideas about what constitutes “real” disease change from time to time due to theory and practice, the symptoms that patients present will change as well. These medical changes give the story of psychosomatic illness its dynamic: the medical “shaping” of symptoms.

Not until the eighteenth century, with the advent of new theories about “nervous disease,” does such shaping begin to change. Patients start the narrative by breaking with an age-old pattern of traditional psychosomatic symptoms. And the doctors’ part of the story commences just as some important scientific advances occur. But these discoveries about the nervous system led to some unscientific theories about how nervous disease arises— theories that would suggest to patients a new pattern of psychosomatic symptoms. The symptom shift thus begins with the rise of such “nervous” symptoms. A set of symptoms, such as hysterical paralysis, arose which was quite specific to the late eighteenth and nineteenth centuries. These symptoms would in the twentieth give way to quite different symptoms—those of chronic fatigue, pain, and allergy sensitivity.

Psychogenic Symptoms

By definition psychogenic physical symptoms arise in the mind, in contrast to somatogenic symptoms, which come from organic disease. To the patient, however, both kinds of symptoms seem the same: Both appear to result from real bodily disease. There is very little cultural shaping of the symptoms of organic disease, and people presumably turned yellow with liver failure in the fourteenth century just as they do in the twentieth (liver disease causes jaundice, giving a yellowish cast to the skin). Although the mind may still edit somatogenic symptoms, they are mainly shaped by organic disease. But the shaping of psychogenic symptoms is left to the fantasy of the unconscious.

Nevertheless, the unconscious is not entirely abandoned to its own resources. The surrounding culture provides our unconscious minds with templates, or models, of illness. If our unconscious decides, for example, that we are to be in pain, it determines how pain will be dealt with: perhaps with the stoic jaw clenching of Anglo-Saxon cultures or with the tying about one’s head of a kerchief, as in Italy. These are examples of culturally determined templates the unconscious uses to instruct itself.

All these templates, or different ways of presenting illness, constitute a symptom pool—the culture’s collective memory of how to behave when ill. For Western society since the Middle Ages, the number of potential symptoms in this pool has been relatively unchanging. Symptoms of headache, tiredness, and a twitching left leg are some of its contents, which have been available for centuries. Some symptoms from other cultures—such as “koro,” a perception among South Asian and Chinese males that the penis is retreating inside the abdomen—do not form part of this pool.1 The symptom pool of the Occident has always harbored certain standard items. Until the middle of the twentieth century, people knew about the contents of this pool from popular culture, an oral tradition that communicated from generation to generation whatever individuals told each other about aches, pains, and other bodily woes. Today the media more than any other conduit tell us about the symptom pool.

The contents of this particular symptom pool are psychogenic, in that all may be caused by the action of the mind. (Turning yellow is not part of the psychosomatic symptom pool.) But headache, tiredness, and a twitching left leg may be caused by organic disease as well, and someone has to decide whether they are psychogenic or somatogenic. Perhaps it is the individual, him- or herself, in deciding whether to seek out the doctor for a particular symptom. Perhaps it is the doctor, in deciding whether to operate or to counsel the patient. In historical studies informed retrospection tries to decide. Yet the decision must be made, or the notion of a well-circumscribed psychogenic symptom pool is meaningless.

In some historical periods certain items in the pool are frequently drawn on, in others scarcely at all. How does the culture of a given period decide which symptoms to select? It depends on representations of what is thought to be legitimate organic disease. No patient wants to select illegitimate symptoms, to become a laughingstock or be dismissed as hysterical. Thus any given period will have a predominant notion of what it considers real disease.

Robert Musil makes this point, in a slightly different context, in his novel about Viennese life at the turn of the century, The Man Without Qualities. Ulrich, the chief protagonist, is thinking about photographs of beautiful women from decades past, and as he tries to achieve some kind of rapport with the faces in the photographs he notices “a whole number of small features which actually constituted the face, and yet which seemed very improbable. All societies have always had every kind of face. But the standards of the day single out one particular face as the dominant one, the essence of happiness and beauty, while all other faces attempt to imitate it.”2 So it is with symptoms. Our bodies send us the most disparate variety of signals about physical sensations. Under some circumstances, we interpret these signals as evidence of disease, but the symptoms into which our minds cast this disease are just as determined by fashion as was the fashionable face of fin-de-siècle Vienna.

These symptoms fall into four general categories: sensory symptoms, such as prickly skin or tiredness; motor symptoms, such as paralysis; symptoms of the autonomic nervous system, such as a churning bowel; and symptoms of psychogenic pain.

Sensory and motor symptoms, the first two groups, belong to the body’s somatosensory nervous system. This is a nervous system with its own privileged pathways. Certain parts of the spinal cord are reserved for it, as are certain areas of the brain. If a young man suddenly developed a loss of feeling in half of his body (and had no organic disease), he would have a psychosomatic sensory symptom. A young woman who awakened one morning unable to walk because of a paralysis of her legs (and had no neurological illness) would belong in the motor category.

A third group of symptoms are autonomic, meaning they are controlled by the autonomic nervous system, which regulates the action of internal organs and the diameter of blood vessels. Thus diarrhea, blushing, a racing pulse, and all kinds of internal sensations come into this category.

Finally, there is psychogenic pain, which means pain that the patient perceives as real but that is not caused by an organic lesion in the body. The pain arises in the mind. If I get a headache as I sit at my word processor thinking how to make this clear, I am suffering a psychogenic headache.

Of course all these symptoms could result from organic diseases too, which is precisely the point. In somatization the unconscious mind chooses symptoms that will be taken as evidence of real, physical disease and that will win the patient an appropriate response.3 Thus most of the symptoms in these four compartments of the symptom pool have always been known to Western society, although they have occurred at different times with different frequencies: Society does not invent symptoms; it retrieves them from the symptom pool.

One objection comes immediately to mind. With the exception of those in the last chapter, the patients described in this book are all dead. Is it certain that their symptoms were not caused by an organic disease? Retrospectively, it is not. There is only the presumption of psychogenesis, based on (a) the history of the illness, such as paralysis after seeing a frog on the road, and (b) the response to what was essentially placebo therapy, such as hydrotherapy or administration of a laxative. These two circumstances give certain symptom patterns a flavor of psychogenesis.

An elderly neurologist in Marseilles told me about young Italian female patients, usually from southern Italy, who would be brought to his clinic—much more prestigious than the Italian clinics—in an ambulance, convulsing and thrashing in fits. “It would take four men to hold them down,” he said. He cured them with sugar pills. He opened his desk drawer to show the three colors of pills he gave, some “stronger” than others. Of course the patients thought they were powerful medicine.

Were these young women epileptic?

“No, hysterical,” he said. “You can smell this quality of hysteria.” He gestured expansively to his nose. “Ça sent de l’hystérie.”

Whatever the cultural reasons for the illness behavior of these southern Italian women—and one may presume many such reasons on the part of powerless young women in a patriarchal society—they probably did not have epilepsy. So it is with many of the men and women in this book: They probably did not have an organic illness, although we cannot be sure.

The Symptom Pool

The pool of psychosomatic symptoms, physical symptoms caused by the action of the mind, has a history. Of the various types of psychosomatic symptoms, those attributable to the motor side of the nervous system are the most colorful. Reaching back into antiquity, they include sudden loss of the power of speech (hysterical aphonia);4 the inability, all at once, to open the eyelids; contractions, incapable of relaxation, of the elbows, wrists and fingers; and failure to get out of bed one morning because the lower limbs are paralyzed. Historically, the commonest of the motor symptoms have been fits, or pseudoepileptic fainting and writhing about. In fits, motor activity is apparently out of control, the limbs twitching histrionically, the eyes turned back in the head, the affected individuals (they do not become “patients” until they see a doctor) often screaming, cursing, and attempting to bite those nearby.5

In the domain of pseudoepilepsy there is truly nothing new under the sun. According to a note in the November 7, 1711, Spectator: “Mr. Freeman had no sooner taken coach, but his lady was taken with a terrible fit of the vapours, which, ’tis feared, will make her miscarry, if not endanger her life.” “After many revolutions in [Mrs. Freeman’s] temper of raging, swooning, railing, fainting, pitying herself and reviling her husband, upon an accidental coming in of a neighbouring lady … she had nothing left for it but to fall in a fit.” Mrs. Freeman was quite accustomed to throwing teacups into the fire and berating the menfolk surrounding her. Whatever the true cause of her unbridled behavior (“this fashionable reigning distemper”), it is unlikely that she had epilepsy.6

Far from London in rustic Edale, Dr. James Clegg went to visit his mother on September 14, 1730: “She was seized whilst I was there with a most violent hysteric fit exactly at the time the moon came to the full. I lodged there that night.”7 Again, Dr. Clegg’s mother probably did not have epileptic attacks at full moon, though we cannot know for sure. There was Mrs. King, thirty years old, of Northfleet and a patient of John Woodward, a distinguished London physician. In the spring of 1705 “a great grief” affected her, whereupon “she fell into a most violent griping pain of her stomach. In a quarter of an hour she perceived a tingling, and afterwards a deadness of her left hand, which gradually ascending up her arm, took her head, when she lost all sense, and became finally cold, stiff, and was thought dead.” Mrs. King had a long and complicated medical history: “She had once a fit upon a fright, in which she lay as dead for three or four hours.” Further: “Upon grief she has had frequently risings in her throat and chokings. A fright affects her back instantly with pain…. It also brings on a flight vertigo and pulsation in her back and head, as also palpitation of the heart with a flushing and heat of her head and face.”8 Thus a whole riot of bodily symptoms could accompany an attack of fits, for somatizing patients often experienced all major varieties of psychosomatic symptoms simultaneously.

Mrs. King’s case merely hints at another kind of motor symptom: globus hystericus, the sensation of a ball rising from the depths of the abdomen and lodging in the throat, whereupon an attack of fits begins. In 1713 a Mrs. Cornforth described to Doctor Woodward what she experienced in such a fit: “First her legs became feeble, so that they would not bear her weight and she could not possibly stand up.” Then back pain commenced: “Immediately her heart begins to throb and palpitate, the throbs pointing at, and forcing [radiating] towards the part of the back so pained; they also force to her arms, neck, and head at the same instant, and the pulsations, in all, keep time exactly with the heart and back.” She feels nauseated, and then “she sensibly perceives something fluid ascend from the place pained in her back up into her shoulders, the scapulae, arms, neck, and head.” At this point Mrs. Cornforth describes much “throbbing” and writhing in her upper body and internal organs. Finally “she feels something descending down her back to her stomach, and the fit is instantly at an end.”9

“Vapours, otherwise called hysterick fits and improperly, fits of the mother,” said London physician John Purcell in 1702, “is a distemper which more generally afflicts humankind than any other whatsoever.” Its symptoms? “First they feel a heaviness upon their breast, a grumbling in their belly, they belch up, and sometimes vomit…. They have a difficulty in breathing and think they feel something that comes up into their throat which is ready to choke them; they struggle, cry out, make odd and inarticulate sounds or mutterings; they perceive a swimming in their heads, a dimness comes over their eyes; they turn pale, are scarce able to stand; their pulse is weak, they shut their eyes, fall down and remain senseless for some time.”10 These are typical accounts of fits, which dominate the motor hysteria scene until well into the nineteenth century.

The motor symptom of inability to walk owing to supposed paralysis of the lower limbs reaches far back into time as well. Occurring chiefly in young women, these psychogenic paralyses would become virtually epidemic in the nineteenth century. But they were not unknown in the seventeenth century, when sufferers sought relief at such watering places as Bath. Thus in 1682 Mrs. Budghill of Exeter, “a comely young gentlewoman” of twenty-five, came to Dr. Robert Pierce, “all parts enfeebled and benumbed, but especially the lower parts, so that she could neither stand nor go, and the sense of feeling was depraved in all parts.” Multiple sclerosis? A spinal tumor? She was “first put into the Queens-Bath, afterwards in the King’s; and after a whiles bathing was pumped [given an enema],” and given various medications, so that she “at length very well recovered the perfect use of, and sense in, all her limbs.”11 Accordingly Mrs. Budghill’s paralysis was probably psychogenic.

The evidence given at canonization hearings for possible saints, reflects the whole range of premodern forms of hysteria. Thus at the hearings for François de Sales, bishop of Geneva, who died in 1622, much testimony was accumulated of miracles performed in the countryside around Annecy in the 1650s in the deceased bishop’s name. Thirty-four of the miracle cures in adults concerned paralyzed and crippled limbs. For example, after a series of maladies, in 1658 the gentleman Roget de la Bisolière found himself “paralyzed in all limbs, particularly below the waist, and since about tw...

Table of contents

• Cover
• Title Page
• Dedication
• Contents
• Preface
• CHAPTER 1 Doctors and Patients at the Outset
• CHAPTER 2 Spinal Irritation
• CHAPTER 3 Reflex Theory and the History of Internal Sensation
• CHAPTER 4 Gynecological Surgery and the Desire for an Operation
• CHAPTER 5 Motor Hysteria
• CHAPTER 6 Dissociation
• CHAPTER 7 Charcot’s Hysteria
• CHAPTER 8 The Doctors Change Paradigms Central Nervous Disease
• CHAPTER 9 Doctors Patients and the Psychological Paradigm
• CHAPTER 10 The Patients’ Paradigm Changes
• CHAPTER 11 Somatization at the End of the Twentieth Century
• Notes
• Index