Popular Science Monthly/Volume 74/June 1909/Hysteria as an Asset
| HYSTERIA AS AN ASSET |
By PEARCE BAILEY, M.D.
ADJUNCT PROFESSOR OF NEUROLOGY, COLUMBIA UNIVERSITY, NEW YORK
AT about the time that Commodore Vanderbilt was establishing in America the methods which made railway travel easy, a book was published in London which left untouched all problems of construction and management, but nevertheless played an important part in the economics of transportation. This book treated of railway injuries and was written by England's foremost surgeon, John Eric Erichsen. It brought together for the first time, in concrete form, the nervous disturbances from which the victims of railway wrecks suffer so severely; and by chronicling the large sums of money awarded in such cases as were litigated, it showed how important an asset "railway spine" might be. It soon became a best seller. It was indispensable to physician and attorney alike; and transportation companies had to have it to protect themselves against the menace of the new. disease. It almost became a court manual at this epoch, when the quickening of railway movement was beginning to crowd court calendars with damage claims. For nearly twenty years it stood unchallenged and without a rival. Its influence was felt the world over, for it carried with it a money importance such as seldom follows the writings of medical men.
All this was half a century ago. Since then, new knowledge and new ways of getting it have shown that Erichsen taught mostly error; and his monograph, once so opportune and never to be stripped of the glory of the pioneer, is nothing now but a historical document. It was a costly book for railway companies. The cases it described were serious and "railway spine" brought large verdicts. It was not until 1882 that its teachings were seriously questioned. Then Page, surgeon for the London and Northwestern Railway, took a hand. In vigorous language, he presented new facts as seen by the railway surgeon. He brought forward the after histories of over two hundred cases of railway injuries and showed, contrary to Erichsen's teachings, that a large proportion of them recovered. He wrote with candor, but being a corporation servant, could not escape the charge of bias.
But Charcot was not biased, and when, in his studies of hysteria, he began to demonstrate the mental origin of many physical symptoms, the subject received its true illumination. Thoughtful physicians could no longer fail to realize that railway injuries are not essentially different from any others; that the mutilations are such as surgeons see resulting from a variety of causes, and that the nervous symptoms which so often follow accidents on railways are mental rather than physical and are the same as originate from any one of a great number of emotional experiences. And so "railway spine" passed away and in its place came physical injuries and several groups of psychic phenomena which a great German called the "traumatic neuroses"—"traumatic" because of the accident, "neuroses" because the nervous system, though out of order, has sustained no physical damage and is capable, sooner or later, of resuming its normal functions.
With the spread of industries and the ever increasing frequency of claims for damages for personal injuries, these cases have become everyday occurrences. Physicians the world over have had abundant opportunity to observe their mode of origin, their course, and (though this with greater difficulty) their final outcome. And there is almost universal agreement of opinion that fright at the time of the accident and anxiety after it are the true causes. The cuts and bruises which must be received if the injury is to be actionable (151 N. Y.) intensify the psychic factors. But they do not cause the nervous symptoms, though they may determine, to some extent, their trend.
That this agreement of opinion is not always manifest when these cases come to court may cause regret but not surprise. Witnesses are not always candid, nor experts always wise. And the individual case itself may present such baffling perplexities that it imposes not only on judge and jury, but on the most learned professors in the land.
In Erichsen's day, diagnosis was uncertain in all the disorders at present called the traumatic neuroses. Now, most of them, such as neurasthenia and the various trains of morbid thought which result from back-strain, can be recognized at their true value by any physician who is reasonably experienced and careful. Not so hysteria. This mocking psychosis, with its tragedy and humor, its counterfeits and its realities, its impositions and its appeals for pity, is ever on the watch to lead the unwary into error.
In September, 1899, in Norfolk, Va., the cart which a healthy farmer was driving was struck violently by a trolley car. The man was for a moment prostrate on the roadway, but whether he was thrown out or had jumped out was one of the questions which perplexed the jury. At any rate, he walked to the sidewalk and then swooned. He was carried to a neighboring house, where he had a series of convulsions. The bystanders, strong men, tried to restrain him, but he threw them off. He then fell to the floor in such a way that only heels and occiput touched it. And in this strange posture, with body arching toward the ceiling like a bow, his frame was shaken during several minutes by violent trepidations. He was finally carried to the hospital, apparently unconscious. No evidences of physical injury were found. But the next day he complained of pain down the whole right side and there were twitchings of the face and arm. A few weeks later he became deaf and dumb and shortly after that lost the use of the right arm and the right leg.
In this condition he was brought to court, eight months after the accident, the most important witness in his suit against the street railway company. There never was a fairer trial. Opposed experts coincided in the view that the plaintiff had received no injury of important organs and that his dramatic symptoms were the physical expressions of idea. It was a tribute to the dignity of honest experts that the judge, in the face of the exhibit, listened calmly to this testimony and that the jury did not laugh out loud. For the poor man seemed sitting in the shadow of the tomb. Emaciated, his face agitated by constant twitchings, his whole right side inert and powerless, hearing nothing, uttering no sound, getting his questions on slips of paper and writing the answers with the left hand (an accomplishment acquired since his illness)—he looked the leaf about to drop, the very essence of decay. Optimist indeed who could believe in his rehabilitation.
The jury disagreed, mainly on the negligence, and the case was settled a few months later out of court. The man recovered, not all at once, but gradually. He now hears everything, and, if his wife is to be believed, talks too much; his muscles have regained their power and, when not busy on the farm, he ferries passengers across a little river in the county of Princess Anne. So the doctors, all of them, were right for once, for hysteria and nothing else can explain a case like this.
As a psychological proposition, this strange malady more than demonstrates the influences of mind on matter—it establishes the dependence of all voluntary expression on idea. It can disrupt mental and physical unity as completely as the most destructive injuries. Its dark shadows flitting in the subconsciousness corners of the mind may stimulate to increased function, or so far suppress function that the affected organ is left without its purpose. Hypersensitiveness, which soon is pain, to light, to sound, to smell and taste, to feeling, may all be products of hysteria when the disorder whips up function; when it paralyzes, the victim must get along as best he can until his sensorial servants come back to work. In the sphere of motion, twitchings, tremors, contractions and even convulsions, bear witness to excess of function; paralysis, to loss of it. These functional perversions, these idealistic symptoms, are cast in the same mold as those of structural disease. But they carry with them tell-tale differences of form and arrangement which permit their true nature to be recognized. Various and many are the hypotheses to explain the psychological enigma. For its last analysis it needs the genius of a Plato. For working purposes, perhaps the theory of Charcot is the most acceptable. He compared the genesis of traumatic hysteria—which alone concerns us here—with the mechanism of hypnosis. The jar, the blow, the fright, like the passes or the artificial aids of the hypnotist, create disorder in the mind. dazing it and reducing it to extreme impressionability. Then follow the suggestions. Verbal from the hypnotist, to the hypnotized victim of the casualty they come from the circumstances of the accident, or what follows it, or from the victim's mind itself, as it reflects on injuries he has seen or heard of resulting from similar disasters. Thus is determined the symptomatic type. Little by little the symptoms spread and deepen—they rarely reach their full development at once—until at last, the patient, sound in wind and limb, may become as inert a mass as ever wheel-chair carried.
As important as the accident itself, or even more so, are the circumstances which follow it. Injudicious sympathy from friends, fears felt by physicians not wise enough to keep them to themselves, the solicitous exaggeration by attorneys and the patient's perception of the financial possibilities of his wrongs, all give new tentacles to the morbid ideas, which burrow deeper among the roots of rational conduct. Left to a physician versed in psychic medicine and rich of conscience, with damage claim thrown out the window, there are few cases of traumatic hysteria, taken at the outset, which a month of vigorous treatment would not cure. But, with the demands of legal procedure ever imminent, such a course is never possible. In Germany and other countries which maintain parental protection of the injured, conditions are even more unfavorable. In these countries, the injured workman is placed on an allowance of money, graded in accordance with his earning, which continues to be paid as long as he is incapacitated. This robs the patient of his spur to effort and tends to prolong the mental instability. As a result, in these countries, or at least in Germany, traumatic hysteria is more protracted and rebellious than it is with us. With us, sooner or later, the case is finished. It may be years before the final card is played; but some day the game is over and the hands are on the table. And then, for the first time since the accident, the injured person has a chance to regain his health. Before there was no chance. For, with the persistence of symptom-inducing suggestions, inseparable from litigation, it is practically unheard of, if not impossible, for a plaintiff to improve in any essential particular before the release is signed or the court-room doors have closed upon him for the last time. This helps to make hysteria the most difficult disease of any found at law of satisfactory settlement out of court.
At the outset, the surgeon for the company, thinking the case is one of temporary shock, reports favorably and the claim agent makes offers of small sums. These are rejected; the plaintiff's physician has seen such symptoms aggravate with time. The attorney feels a conscientious duty toward his client and must know the way things are going before settlement is thought of. While they all thus solicitously wait, the gloomiest fears are realized. Paralysis sets in. By this time the dangerous character of the case dawns on the defendant. Head surgeons and neurologists are sent. These report the facts which usually are conspicuous enough. The patient gets still worse. All chances of settlement on any reasonable basis are now gone and the case finds its way to court. Once in the court-room, the patient is at the acme of all the symptoms. Paralysis, insensibility to pain, convulsions, loss of special senses, all make profound impressions on judge and jury. The medical opinions are too often flatly contradictory; and the jurors, thus deprived of the advantage of special knowledge, judge for themselves from what they see.
The verdicts are always large. None too large, perhaps, as actual amounts, in view of the suffering and delays the plaintiffs have gone through. But excessive when compared with the amounts paid for other injuries, more modest in their symptoms, but with far less hopeful outcome. A young girl with hysteria can generally secure a higher compensation in the courts than a working man with some lifelong disability. The amounts thus unjustly graded may indicate that juries can not grasp the dramatic power of idea; or else that they believe that symptoms conjured up from subconscious depths are even more persistent than those of tangible causation.
In strong contrast to the verdicts is the fact that hysteria from injury, in America at least, is cured in nearly every case. Such is my personal conviction,[1] based upon information obtained about the plaintiffs after the suit is closed. Into a detailed examination it is rarely possible to go. For after the trial these individuals, with surprising frequency, fold their tents and silently steal away. Those that remain within a reasonable radius rebel at the idea of reexamination. They seem to resent their recovery. A young man who was injured in one of the terrible wrecks occurring near New York a few years ago, lay in bed for two years with hysterical paralysis, awaiting the trial of his case. There were two trials. At each of them he heard, from his stretcher, his experts say his injuries were permanent. In spite of that he was up and walking freely and was commuting to his work, as he used to do, within eighteen months of the last trial. But a request, prompted by the writer, for permission to reexamine him, brought a response to the effect that "no information would be vouchsafed which could in any way be used to prevent others who had suffered as he had from being less generously compensated."
From such information as is obtainable, it would seem that full functional recovery is the rule. The women who were cripples often marry, the men return to work. But their assumptions or resumptions of activity are often slow. The patients may be well again in a few months. But the miraculous and instantaneous recoveries, such as we hear of in the faith cures, or such as corporation partisans maintain follow quick on payment, do not come within the range of medical experience. It is always several months, sometimes a year or two or maybe even longer, before disabling symptoms disappear.
The farmer whose case has already been described suffered pain and disability for a year after his suit was finished and it was four years before he recovered speech and hearing.
Litigation permits no let-ups in the disease creating suggestions; and the longer the litigation period, the longer, other things being equal, the time required for cure. In the case of a young man injured in Washington, D. C., there were eight years between the accident and final verdict. During this considerable fraction of his life, the plaintiff was glued to his chair, the victim of paralysis from idea.[2] I am still confident of his recovery, though even now, eighteen months after the finish of the legal contest, he has not begun to walk.
The mechanism of recovery in these litigated cases is different than in the ones reported from the shrines of healing. In these latter, the priests make new suggestions, getting at the soul through anticipation, faith and religious fervor. In traumatic hysteria, the cures take place, not so much from fresh suggestions as from removal of those which worked the injury. New springs of action are not tapped; but the stones which blocked the old ones are one by one removed. Once the case is settled, the attorney's sympathy becomes homeopathic in its dosage; the physician abandons the contingent fee; family and friends, worn out by watching and satisfied at last that the patient will not die, resume their wonted occupations. The invalid is left, more and more alone. Under the fillip of neglect, the fixed ideas show signs of weakening. The patient reflects less and less upon his injury and begins to see, in the distance, perhaps, but every day more clearly, the smiling visage of Hygeia. His interest now is to regain his health and enjoy his money, as before it was to stay ill enough to get it. Little by little, he regains his balance and begins to hobble about the room. New trials and achievements add to his confidence, though he has occasional relapses. 'He gets out on the street and finds himself more capable than they ever let him think he would be. Then under the stress of some emotion, or forced by some sudden danger, the part paralyzed springs into pristine being; and soon after he resumes his work.
It has long been held that such cases are the products of voluntary creation and that the hysteric is an actor and a fraud. Such a view is surely wrong. No actor can ever equal the mimetic powers of this wonderful psychosis; and even if the hysteric is a fraud, who, at times, is not? The disease reflects, to some extent, the normal nature of its victims; but it reflects still more the environment in which it is born and lives and dies.
Postscript
After this article was in type and the proof had been returned to the editor there was received from the plaintiff's attorney in this action the following letter, written by the plaintiff's wife:
Washington, D. C., April 26th, 1909.
My dear Mr. S:—
I fear that I am too happy to express myself intelligently, but you can understand the cause when I say Mr. P. has walked and it came about from a fright produced by the falling of plaster from the ceiling at three o'clock in the morning. Of course we were all sound asleep and when the crash came, I thought some one had bursted in the door and I went into hysterical convulsions and Mr. P. found himself several feet from the bed. He is very weak, but the Doctor says that he thinks he will gradually regain his strength as the sensibility has returned to his limbs. Oh, we all are so supremely happy and I feel sure that the Lord in his own good time will restore my boy to health.
| Very respectfully, |
| Mrs. V P. |