Edward Shorter - From Paralysis to Fatigue

A History of Psychosomatic Illness in the Modern Era

Edward Shorter

THE FREE PRESS
New York

THE FREE PRESS
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Copyright 1992 by Edward Shorter

All rights reserved, including the right of reproduction in whole or in part in any form.

THE FREE PRESS and colophon are trademarks of Simon & Schuster Inc.

First Free Press Paperback Edition 1993

Manufactured in the United States of America

printing number

10 9 8 7 6 5 4 3 2

Library of Congress Cataloging-in Publication Data

Shorter, Edward.

From paralysis to fatigue : a history of psychosomatic illness in the modern era / Edward Shorter.

p. cm.

Includes bibliographical references and index.

ISBN 0-02-928667-0

eISBN 978-1-439-10564-1

1. Medicine, PsychosomaticSocial aspectsHistory. 2. Somatoform disordersSocial aspectsHistory. 3. Social medicine. I. Title.

[DNLM: 1. Fatiguepsychology. 2. Paralysispsychology. 3. Psychophysiologic Disorders. 4. Psychosomatic Medicinehistory. 5. Social Environment. WM 90 S559f]

RC49.S435 1992

616.0019dc20

DNLM/DLC

for Library of Congress 91-24912

CIP

To my parents, Joan and Lazar Shorter, in gratitude

The history of psychosomatic illness in the modern era is a complex and sometimes tangled tale. The present work provides the essential narrative of the story, beginning with such notions as hysteria in the eighteenth century, and continuing into our own time with such contemporary disorders as chronic fatigue syndrome. It is a history of shifting maladies as experienced by patients and perceived by doctors, an account of how historical eras shape their own symptoms of illness. (A future work will focus on the social and biological themes in psychosomatic illness, seen in historical perspective.)

It should be emphasized at the beginning that from the patients viewpoint psychosomatic problems qualify as genuine diseases. There is nothing imaginary or simulated about the patients perception of his or her illness. Although the symptom may be psychogenic, the pain or the grinding fatigue is very real. The patient cannot abolish the symptoms by obeying the simple injunction to pull up your socks, for what he or she experiences is caused by the action of the unconscious mind, over which he or she by definition has no rational control. Thus this book does not view patients with somatoform symptoms as bizarre objects but as individuals who enjoy the dignity that all disease confers; our task is rather to understand why the kinds of psychosomatic symptoms that patients perceive change so much over the ages.

Because I am a historian, the interplay between culture and the problems of the individual interests me. Here the unconscious mind intervenes. In psychosomatic illness the bodys response to stress or unhappiness is orchestrated by the unconscious. The unconscious mind, just like the conscious, is influenced by the surrounding culture, which has models of what it considers to be legitimate and illegitimate symptoms. Legitimate symptoms are ascribed to an underlying organic disease for which the patient could not possibly be blamed. Illegitimate ones, by contrast, may be thought due to playacting or silliness. By defining certain symptoms as illegitimate, a culture strongly encourages patients not to develop them or to risk being thought undeserving individuals with no real medical problems. Accordingly there is great pressure on the unconscious mind to produce only legitimate symptoms.

This cultural pressure is the crux of the book. The unconscious mind desires to be taken seriously and not be ridiculed. It will therefore strive to present symptoms that always seem, to the surrounding culture, legitimate evidence of organic disease. This striving introduces a historical dimension. As the culture changes its mind about what is legitimate disease and what is not, the pattern of psychosomatic illness changes. For example, a sudden increase in the number of young women who are unable to get out of bed because their legs are paralyzed may tell us something about how the surrounding culture views women and how it expects them to perform their roles.

Psychosomatic illness is any illness in which physical symptoms, produced by the action of the unconscious mind, are defined by the individual as evidence of organic disease and for which medical help is sought. This process of somatization comes in two forms. In one no physical lesion of any kind exists and the symptoms are literally psychogenic; that is to say, they arise in the mind. In the second an organic lesion does exist, but the patients response to ithis or her illness behavioris exaggerated or inappropriate. Culture intervenes in both forms, legislating what is legitimate, and mandating what constitutes an appropriate response to disease. Our late-twentieth-century culture, for example, which values individual dynamism, regards physical paralysis and sudden coma (both common before 1900) as inappropriate responses.

Psychosomatic illnesses have always existed, because psychogenesisthe conversion of stress or psychological problems into physical symptomsis one of natures basic mechanisms in mobilizing the body to cope with mental distress. People have always tried to achieve some kind of plausible interpretation of their physical sensations. They cast these sensations on the model of well-defined medical symptoms available in a kind of symptom pool. Only when an individuals act of making sense amplifies the sensations, or attributes them to disease when none exists, does psychosomatic illness come into play.

The two actors in this psychodrama of making sense of ones sensations are, and always have been, doctors and patients. The interaction between doctors and patients determines how psychosomatic symptoms change over the years. Doctors notions of what constitutes genuine organicity may alter, perhaps as a result of increased scientific knowledge or of new cultural preconceptions. Although patients notions of disease tend to follow doctors ideasa kind of obedience that has started to break down at the end of the twentieth centurypatients may also change their notions of the legitimacy of symptoms for reasons that have little to do with medicine. The point remains, however, that the relationship between doctors and patients is reciprocal: As the ideas of either party about what constitutes legitimate organic disease change, the other member of the duo will respond. Thus the history of psychosomatic illness is one of ever-changing steps in a pas de deux between doctor and patient.

This book begins with the late-eighteenth-century status quo and brings the story up to the present. The nature of psychosomatic symptoms changed relatively little before the second half of the eighteenth century. Premodern patients responded not to an official medical culture but to a fairly constant and unchanging body of unofficial medical folklore that was probably a thousand years old. Before 1750 doctors, too, believed in a relatively unchanging core of humoral medical doctrines, the basic components of which reached back to the ancient Greeks. Then, after the mid-eighteenth century, the presentation of psychosomatic illness began to varychanges reflected in the following chapters.

Finishing in the present exposes one to all the risks of writing contemporary history, in which the underlying factors do not stand out from the superficial detail with the clarity lent by remoter times. Still, as a historian, I am attracted by the idea (however illusory and deceptive it might be) of using the past to illuminate todays problems. So striking is the impact of culture on psychosomatic illness, that both doctors and patients today might learn something by seeing medical symptoms, which are considered intensely personal and idiosyncratic, in light of the past.