The Scientific Review of Alternative Medicine

People have historically attributed the causes of symptoms of illness in ways that are congruent with the expectations, values, and belief systems of their societies. In European countries, the dancing manias that followed the black plague were attributed to demonic possession or the torment of sins. Except in Italy, where it was attributed to the bite of the tarantula. From the perspective of modern society, we can see that cultural forces produced these outbursts, but many people are now fearful of the chemicals that assist in our survival. Some claim that even brief exposure to small amounts of chemicals gives them serious symptoms. Scientific practitioners should use sensitive clinical skills in the assessment and management of these individuals’ problems.

Note: An earlier version of this paper was published in The Scientific Review of Mental Health Practice in 2002 under the title “Hard Times, Dancing Manias, and Multiple Chemical Sensitivity.”

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Throughout history, individuals have attributed the causes of symptoms in ways that are congruent with the expectations, values, and belief systems of their society. For example, in most European countries, the dancing manias that followed the black-death plague were attributed to demonic possession or the torment of sins. However, in Italy, the dancing mania was attributed to the bite of the tarantula. Just as priests were unsuccessful in managing the dancers who sought their assistance, physicians were also powerless in treating the victims of this malady. As modern society has developed, we have seen that cultural forces produced these outbursts but that Italians nonetheless obtained specific advantages in attributing certain consequences of their socio-religious turmoil to biological causes.

As modern society developed, many people remained fearful of the chemicals that have assisted our survival. Indeed, some claim that even brief exposure to small amounts of chemicals gives them serious symptoms. Individuals who claim Multiple Chemical Sensitivity also prefer biological explanations for their symptoms. Scientific practitioners must not abandon these patients to quacks but should instead use sensitive clinical skills in the assessment and management of these individuals’ problems.

But then the question is, whether all this be true? Let us be well assured of the matter of fact, before we trouble our selves with enquiring into the cause. It is true, that this method is too slow for the greatest part of mankind, who run naturally to the cause, and pass over the truth of the matter of fact; but for my part, I will not be so ridiculous as to find out a cause for what is not.

—deFontenelle, The History of Oracles, 1686

What in observation is loose and vague, is in information deceptive and treacherous.

—Francis Bacon, Novum Organum, 1620

It is impossible to live in our society without exposure to chemicals. Certain individuals believe these chemicals are toxic to them, but the diagnosis they claim, Multiple Chemical Sensitivity, is in dispute. What should a responsible clinician do?

Physicians confronted this same question in the 14th century when faced with the assessment and management of an unusual movement disorder known as dancing mania. In this paper, I review the cultural circumstances from which these dancing manias emerged, the confusions they caused, and the insights they provide for the current controversy over Multiple Chemical
Sensitivity and related disorders. A primary struggle, I propose, has been over the cause of symptoms. Thus, I focus here on conflicts of attribution.

Hard Times

Human history shows how capriciously our species has been buffeted by the forces of nature.a For example, we know from the written records of Europe that life became more difficult to sustain at the beginning of the 14th century as the climate became wetter and colder. The Baltic Sea and the Thames River periodically froze over. In such circumstances, livestock animals rarely survived over the winter because their food and water froze. Sometimes people saved breeding stock by moving them into the family household. Also, the cultivation of grain was essentially extinguished in Iceland and Scandinavia as glaciers pushed south. Even in the most productive agricultural regions of England, grain production dropped as low as a one- or two-fold yield from the five- or six-fold

yields that had been attained in the previous century. Crop failures were common because of heavy rains, floods, frosts, violent winds, and hailstorms.¹

In early pagan Europe, religious traditions had been established to protect vulnerable communities from the uncertainties of life. Select men and women who were acknowledged as wizards and witches were responsible for ensuring good harvests through their leadership in festival rituals, prayers, and battles they waged in visions.² Then, as Christianity gradually became the official state religion, Christian priests competed with these indigenous pagan traditions for the loyalty of people. This power struggle played out, in part, through competition over who could best protect the people and their crops.

Each party battled over who could better exercise control over nature by enlisting the assistance of more powerful supernatural forces.³ St. Augustine (354–430) suggested that Christianity would be more successful in expanding into pagan Europe if it adopted and modified existing festivals and traditions. As the church gained power, the early inquisitors were told to leave the superstitious old witches alone. But gradually, the pagan belief system began to be viewed by the Church as wrong and then as evil.⁴

The superstitious witches who had played an important social role and had conducted rituals for successful harvests were gradually viewed as consorting with the devil to destroy crops.

One aspect of how this change occurred was investigated by Ginzburg,² who reviewed the detailed depositions of very early inquisitions. He showed one specific example in which accused persons changed their answers to appear more sympathetic to the Christian schema. At the same time, the inquisitors developed a schema, based on these answers, about how the devil worked in this pagan society. Ginzburg showed that these early interactions, even before the use of torture, resulted in each side developing a false view of reality of the other.b

Some early Christians believed that God alone could send down storms, which only holy men could disrupt with their prayers. However, this belief evolved into the notion that storms were caused by the activities of witches. This association is illustrated in contemporary pictures that show the witch flying through a storm on her way to a sabbat. The relationship between storm and witch was explicitly stated in the 1437 bull issued by Pope Eugene IV, who exhorted inquisitors to use greater diligence against those human agents who produced bad weather. Pope Innocent VIII was also eager to identify-and eliminate those responsible for foul weather that destroyed crops. Behind the witch, of course, were the devil and his agents. Pope Gregory spelled out a detailed exorcism to expel evil spirits from the air. Pope Urban V sold wax cakes embedded with his papal stamp that could be buried in fields for protection. Pope John XIII established the practice of baptizing church bells which were rung during storms to dissipate thunder by frightening the devil, who was believed to be the “Prince of the power of the air.”⁶

More Obvious Responsible Agents

Sometimes, the agents deemed responsible for hard times were more obvious. For example, the 14th century was also characterized by unrelenting wars. Invading troops often killed civilians, confiscated the existing food supply, and destroyed crops, vineyards, and orchards so that the land could not be reoccupied by the enemy. Even in periods of peace, unemployed soldiers banded together to pillage the property and possessions of their own countrymen. These natural and man-made disasters resulted in massive crop failures, fields being left fallow, and even the loss of basic agricultural knowledge. In addition, methods of storing and transporting food were generally so poor that starvation in local areas was common.

Crop losses from insects and vermin during these times are difficult to comprehend from today’s perspective. For management, people resorted to methods they believed would be effective, such as exorcism, enchantments, holy water, and fantastic rituals. Magic books contained secret formulas for pest control.⁷ Insects, like strikes of lightning, were considered to be either a chastisement by God or a vexation inflicted by Satan. Rats were called the imps of the devil, and are often shown pictured with witches. Civil and ecclesiastic trials were held for the prosecution and punishment of these offending creatures. Bartholomew Chessenee (b. 1480) made his reputation as a lawyer by representing rats that had destroyed the barley crop in a French province. He employed “all sorts of legal shifts and chicane, dilatory pleas and other technical objections, hoping thereby to find some loophole in the meshes of the law through which the accused might escape, or at least to defer and mitigate the sentence of the judge.”⁸

In addition to being responsible for crop losses, rats were also the unidentified culprits of the bubonic plague. Plagues have profoundly affected human history. Smallpox killed one third of the citizens of the Roman Empire, and evidence suggests that malaria was perhaps a major cause of the fall of Rome. With the assistance of smallpox and a few hundred men, Cortez conquered millions of citizens and vast areas of the Aztec empire. Those who survived smallpox were struck by measles, typhus, influenza, diphtheria, or mumps introduced by Europeans who had developed some natural immunity through centuries of exposure. Civil records seldom provide accurate information on death rates, forcing historians to guess or, more likely, to reiterate the exaggerated rates of death described in historical reports. We do know, however, that during the Crimean War of the 19th century, more than ten lives were lost to dysentery for every life lost in battle,⁹ an ignoble death for any soldier.

However, the effects of the bubonic plagues can scarcely be exaggerated. These plagues were known as early as the first century, often coming in 2- to 20-year cycles. Then, in the middle of the 14th century, bubonic plague exploded into what became known as the Black Death.^10–12 As it spread around the world, probably one third of the human race was removed from the earth. India was described as depopulated, even though its caste system had probably evolved as a method of quarantine and protection against plagues. Perhaps half the population of England was lost, and throughout Europe, death rates from 50 to 90 percent in local areas were not uncommon. The general population declined irregularly but persistently until about 1440. Death was so unpredictable in its pattern, so vicious in its attack, and so swift in its finality that many had difficulty attributing this calamity to the hand of God. The plague seemed so meaningless that it damaged people’s view that everything was produced and upheld by God’s will.¹³ Barbara Tuchman¹⁴ suggested that questions raised during this time could never be shut out again, and to that extent, she opined, the Black Death may have been the unrecognized beginning of modern man. Later, I return to discuss what Tuchman meant by this statement.

Dancing Mania

At first glance, it is difficult to find evidence of “modern man” following the Black Death of 1358. On the heels of this plague followed flagellants, inquisitors, more crusades, and dancing manias.¹⁵ Although dancing manias had been known from earlier times, a serious epidemic occurred in Germany in 1374. The afflicted displayed a convulsive malady affecting mainly the extremities, face, head, and neck. The disease was associated with malfunction of the digestive organs, a variable but often ravenous appetite, tumescence of the stomach, and continued convulsive movements during sleep. For relief, victims wound tight bands around their stomachs or implored people to trample on them. But the primary presentation was dancing. Victims danced for hours with apparent loss of sensation and reason, furiously impelled with limbs contorted by violent paroxysms. When exhausted, they sank to the ground, insensible to sound or pain.^16,17

Some of the symptoms, as described at that time, have the ring of an organic disorder. Various neurologic conditions such as epileptic seizures, choreas, dyskinesias, Tourette’s syndrome, and neuromyesthesia have been suggested as explanations. St. Vitus Dance was an infectious disease that causes uncontrollable movements. Natural toxins, such as ergot poisoning from the mold spores on rye grains, can also cause unusual symptoms.^18,19

Many of the symptoms, however, sound too bizarre to be believed. Perhaps some were merely second-hand reports, and others were certainly created by the pens of moralists commenting on the deviance they observed. Yet, it should be noted that a vast array of highly unusual symptoms have also been described in recent times during outbreaks of mass psychogenic illnesses.²⁰ Indeed, modern authors now attribute most instances of dancing mania to some form of contagious hysteria or sociopolitical expression.

In Germany and other parts of Europe, the dancing manias were associated with fanatical expressions of religious conflict. Afflicted persons generally attributed their symptoms to demonic possession or to being tormented by sins. In Liege, the victims raged against the folly of the world, denouncing the worldly fashion of pointy-toed shoes, which represented social decadence, perhaps somewhat like the 1960s’ concern about men wearing long hair and women wearing trousers in professional settings. (Today’s younger generation can hardly comprehend the social conflict created by these relatively recent social phenomena.)

Political and religious authorities were at a loss to manage the turmoil. Sometimes, guardians were appointed to watch over victims, to play music that they demanded, or to aide them in pilgrimages to certain chapels such as those devoted to St. John and St. Vitus. There, special services were held for healing or casting out demons.

Not all dancing manias, however, were associated with religious turmoil. In Italy, the dancing manias were attributed to an environmental toxin: the bite of the tarantula.

Tarantism

Concerns about toxins probably began with the first snake bite or bee sting.²¹ Fear of poisons emerged more seriously around the 8th century, when Arab alchemists introduced white arsenic (arsenious acid) into Europe. Easily mixed with food or drink, it was the first colorless, odorless, and tasteless poison. Arsenic has been the poison of choice over the centuries, and at times, as was the case immediately before the French Revolution, it may have been used in epidemic proportions.²² More often, however, serious panics were caused by rumors of its use. Many Jews were tortured into confessing that they were responsible for poisoning wells, especially during the Black Death plague. Death by poisoning was so feared that in 1531, Henry VIII of England made murder by poison punishable by being boiled alive. Hence, the origin of the exhortation to “keep out of hot water.”²³

Beginning in the 13th century, there were concerns about the toxin of a spider in Italy near the city of Tarento. These Tarento spiders, tarantulas, were believed to be the cause of the dancing mania in Italy. Athanasius Kircher (1602–1680), a scholarly Jesuit, drew pictures of these dreaded spiders, described the symptoms of victims, and wrote down some of the tunes devised specifically for the dancers.^24,25 These tunes and certain dances inspired by the mania are known today as “tarentellas.”

The symptoms of the Italian dancing mania (“tarantism”) were similar to those in the rest of Europe, although wide variations occurred within specific episodes, across locations, and over time. Sometimes after being bitten, victims believed they heard voices or musical instruments that caused them to leap, dance, or run wildly. Other victims did not immediately have such experiences but instead experienced loss of appetite, burning fever, pains in the joints, difficulty breathing, chest pain, headache, giddiness, vomiting, and depression. Whereas certain colors were usually offensive to victims in Germany, the Italians were often attracted to yellow or red, as well as to shiny metals, buttons, or swords. Some had morbid fits of love, usually focused on someone who could not return that love. Some stared incessantly at the sea, often with melancholy or weeping.

The Italian fits of dancing usually occurred during the summer, when the poisonous toxins were believed to be inflamed by heat—or by music. Almost all victims of the tarantula bite had great sensitivity to music, jumping up at the first sound and dancing with joy or abandonment. Music was considered a curative, either because the violent dancing was a way of sweating out the toxins of the spider or because it calmed the inflamed nervous system.

On the other hand, music was sometimes more of a problem than a solution. Roving bands of musicians wandered from town to town in the summer. The musicians started as helpers and healers but became problematic when they became roving vagabonds and scoundrels. Sometimes, dancers followed them from city to city like modern groupies. In each new place, observers were lured into dancing by the mesmerizing music and the wild excitement. Those bitten by the tarantula, however, believed that music was the only way of saving their lives. And the following year, the same process started again.

The cause of tarantism could not have been the tarantula. This spider had been described centuries earlier, and such an obvious symptom as dancing had never been mentioned in connection with its bite. The poison of the spider was probably no worse than that of a wasp. Tarantism was caused by the same mechanism as the dancing manias in other places. The only difference seemed to be that victims of tarantism in Italy wanted a biological attribution for what was elsewhere understood as a religious affliction. And physicians were willing to endorse that attribution.

The Lure of Popular Attribution

A review of Thorndike’s History of Magic and Experimental Science26 shows that with apparent unanimity, physicians believed that tarantulas could cause dancing mania, even those living in areas where the same symptoms were
commonly attributed to religious fervor. It made perfect sense to them that the dancing returned each year, usually on the anniversary of the bite, because it was entirely consistent with astrological principles. Indeed, they believed that this was the evidence astrology was correct.

In 1660, Daniel Voel, a doctor of medicine at the University of Utrecht, proposed that dancing mania needed occult treatment, because the bite of the tarantula (like the bite of mad dogs, vipers, and pests) was an occult event.c There was no shortage of occult ideas about the tarantula and its bite. Niccolo Cabeo, a Jesuit of Parma, who wrote on meteorology and astrology, performed an “experiment” to show that the effect of the tarantula’s bite was ended as soon as the spider died. Others believed that the dancing caused the death of the spider, although Gormann believed that music would revive a dead tarantula. A French physician claimed that music would not cure anyone who drank wine in which the spider had died.

There were many ideas about the music that cured the dancing mania. Kircher, for example, believed that different kinds of tarantulas were excited by different kinds of music, and Charleton said that different victims required different tunes and different musical instruments depending on the spider that bit them. In an attempt to provide individual treatment, musicians of Taranto sought out different tarantulas in an attempt to find out what tunes a given spider would dance to. Then, that tune would be considered effective for the victim of that spider bite. Nonmusical treatments included such practices as applying a dead scorpion to the site of the tarantula wound, which would absorb the poison.

All of these theories gave rise to alternative speculations. For example, Groche doubted that throwing the blood of a cow into a fire would help the tarantula victim. Frommann said that the bite of the spider was not relieved directly by music but through a more complex process. He claimed that the music gradually reassembled the animal spirit that was put into disarray by the bite of the tarantula. When the victims danced, they were roused to perspire so profusely that the idea of the tarantula exuded with the sweat.

Some physicians proposed more naturalistic explanations of the spider’s toxin. For example, Gassundi laid down the principles that there can be no effect without a cause, no cause without motion, and no action at a distance without contact. Reason, then, forced him to conclude that the dance of the victim was explained by the venom that altered the temper of the body, especially the organ of hearing so that it responded to music in a way similar to how the tarantula itself would respond.

John Webster, the man who argued so boldly against accusations of witchcraft,²⁷ said that diseases attributed to evil spirits or witchcraft were a fancy, so they could be best treated with a charm or amulet because people believed in the efficacy of such items. Charms and amulets in themselves were in fact “inefficacious, fallacious, superstitious, and groundless.”²⁶(8:578) Nevertheless, he suggested that words framed or enclosed in certain rhythms might, without superstition, cure epilepsy. This would work, he proposed, because the breath altered the air, which then entered the pores. As evidence, he offered the example of music that cures the bite of the tarantula.

No one laughed when these physicians and scholars presented their ideas on tarantism. They were the brightest minds of the day, writing to disseminate their wisdom to a wider audience. Their ideas seem foolish to us today, because they are outside the current zeitgeist. To discover what is currently popular, the reader can search the net for sites on Multiple Chemical Sensitivity. You will find attributions and treatments that seem just as absurd as those that Thorndike found on tarantism. Yet, these Web sites successfully recruit patients, because they present ideas that resonate with many people in our modern society.

The Historical Context Influences Attributions

In the 14th century, the cause of disease was not understood, which is in some instances still the case today. However, that does not restrain our eagerness to support our belief about the cause and management of a disorder.²⁸ Consider the attributions made about the two different dancing manias. Most people in Europe attributed the symptoms of dancing mania to the mischief of devils. The treatment of choice was exorcism. From today’s perspective, we can see that these dancing manias reflected and contributed to religious turmoil.

As noted earlier, the Black Death exerted a profound effect on the religious belief systems of those who survived. People saw that priests had abandoned their responsibility for giving last rites, and the church had no intervention or explanation for the devastation. There was general moral chaos as well. Husbands abandoned their wives, and parents abandoned their children. Neighbor no longer helped neighbor. Those who were able fled into isolation during the plague. As the plague burned out, survivors did not come together in mutual support but instead lived for their own pleasure as if they might not see tomorrow. Among those who retained their faith, the sale of indulgences increased. But some were overwhelmed with the horror and confusion.
Victims of the dancing manias seemed to be protesting this new moral collapse by raging against the decadent fashions as represented by those pointy-toed shoes. The loss of moral compass in individuals was also evident in governments. Surviving rulers ruthlessly grabbed power in all settings that had been weakened by the plague’s destruction. Community safety and cooperation in the feudal system were destroyed forever. Individuals faced a violent, tormented, bewildering age, and as Tuchman observed, many believed that Satan had triumphed. Someone said that hell was empty because all the devils were living on earth. Dancing mania victims were filled with those devils. They sought exorcism and healing, but nothing quieted the turmoil that beset society and the church.

Meanwhile, in Italy, where the dancing manias were attributed—or misattributed—to the bite of the spider, religious attributions were never considered. Early folk practices in Italy had always included music, dancing, eroticism, and ecstatic states. However, all of these pagan practices were discouraged when Christianity became the official state religion following the conversion of Roman Emperor Constantine. Thus, these rituals could be practiced with impunity only if some outside agent were responsible. Tarantism also revived career opportunities for musicians, who were otherwise forced to play religious music or face condemnation. Some municipalities hired these creative players for a week as they moved from town to town throughout the summer.

Medical knowledge in the Middle Ages was not sufficiently sophisticated to sort out symptoms of organic disease from sociogenic outbursts. Thus, it is difficult to fault practitioners of those days for failing to understand and manage what confronted them in tarantism. They certainly can be forgiven if we admit that we have not done much better with today’s Multiple Chemical Sensitivity and the other syndromes that quickly come and go in popularity. Despite all the advantages of chemicals that have improved our health and extended our life, we have not been so successful in extinguishing the fears within us, real or imagined.

But certainly, the chorus chides, you are not going to dismiss all these people with Multiple Chemical Sensitivity as simply victims of fear and imagination. Advances in science should also make us humble. We now know there is much yet to be learned about the effects of the thousands of chemicals that flood our lives. Also, many people who claim to suffer from Multiple Chemical Sensitivity may have disorders that are yet to be discovered, or worse, they may have disorders we already understand but have not yet considered as a diagnosis for them. Thus, it is not surprising that clinicians everywhere stand paralyzed.

‘Modern Man’ and the Beginning of Science

Given the turmoil following the Black Death, what did Tuchman mean when she said that the Black Death marked the beginning of “modern man?” I believe she understood the 14th century as the point in history when individuals began to construct their own meaning of worth and separateness.²⁹

Previously, most people defined themselves according to their role as structured by their community and the Church. Individuality, curiosity, and diversity all threaten stability and certainty. For example, William of Ockham (c.1288–c.1348) was excommunicated because he raised the possibility that intuitive reasoning might provide knowledge of the physical world. As a Franciscan, he also challenged the idea that the pope should have power over the emperor, a consideration that earned him time in the papal dungeon at Avignon. However, the power of the Church to control ideas began to fall apart with the Black Death, because it was evident that priests died as quickly as peasants.

With all its claims of control,^30,31 the Church had no power to stop this chastisement of God or to end this vexation of the devil, whichever it was. Whole religious communities, like convents and monasteries, were completely destroyed because close living quarters increased opportunity for infection.d At least two thirds of all churches in England lost their clergy. Because of so many deaths, the Church rapidly acquired great landholdings by inheritance, then incurred the wrath of individuals and nations by demanding more taxes as was their prerogative. Illiterate and unqualified clergy were assigned to bereaved parishes, often through simony.

The authority of the Church was further weakened by the Great Schism of 1378–1417 which, was marked by the reign of two rival popes, Urban VI in Avignon and Clement VII in Rome. During this period, Urban and Clement each imprisoned followers of his rival, confiscated land, and appointed his own civil rulers.³² Because each had excommunicated those loyal to the other, people joked that no one could enter the kingdom of heaven. During this time of vulnerability, the Church was seriously threatened by the ideas of dissenters, mystics, flagellants, political opportunists, and reformers. For example, Oxford theologian John Wyclif (1330–1384), who preceding Martin Luther by more than a century, argued against the role of priests as the couriers of God’s message.³³ Wyclif translated the Bible into common English, thereby taking truth from the hands of priests and placing it in the hand of each individual. The power of conferring salvation was thus snatched from the Church and given to the individual. When once asked about the value of an ecclesiastical pardon, Wyclif said something to the effect that the parchment on which it was written could be used to hold a mustard plaster in place. Because he was given to such utterances, his bones were later dug up and burned. The burning of bones (dead or alive), denunciations, trials, and torture became increasingly virulent as the Church tried to control dissent. The critical struggle of the inquisition was about who determined truth. Witches were burned for consorting with the devil, but the main concern of the inquisition was ideas—beliefs—not behavior.^34,35

Wyclif’s disdain about the value of a pardon is of profound significance. Wyclif was thinking “outside the box,” looking at a situation and describing what he saw in a new way. People were no longer looking through the peephole constructed by religious authority. It became possible for individuals to consider other views of the physical and spiritual world. Galileo would soon look through a peephole of his own construction.

The Church of Rome tried to suppress the ideas of Galileo, as everyone knows, but it was Prince Leopold Medici of Tuscany who had a plan of action. Realizing the importance of Galileo’s new way of finding truth, he organized the first scientific laboratory for empirical research in 1657.³⁶ Leopold and his colleagues were determined to show the that truth could be uncovered through careful observation, as Galileo had ventured. Understanding fully their challenge to the Church, they wanted to make absolutely certain that their results were indisputable, that mysterious reactions could be attributed to natural processes. Aristotelian Christianity at that time held that effects not directly perceived by the senses were likely the result of occult powers, and thus it was unlikely that God wanted ordinary men to explore these mystic, or perhaps demonic, forces.³⁷ Questionable experiments were thrown out, and they repeated some of the experiments critical to their book, Saggi di Naturali Esperienze (1667). To ensure clarity, they employed the services of a poet, who wrote and rewrote endless drafts. All of this anticipated the demand for reliability and validity in science.

The procedures devised in Leopold’s Academy of Experiment provide a compelling example of protection against false attribution. While studying the rings of Saturn, they set up a model of the planet inside a long hallway and illuminated it with torches that were out of the line of vision. They saw exactly what Huygens, the Dutch astronomer, had predicted. Then, they had second thoughts. Was their conclusion influenced by the hypothesis they believed was correct? What if they were deceiving themselves? Their elegant solution was to enlist people off the street, some of them illiterate, to describe and draw what they observed.

By merely reporting their results and avoiding discussion of the implications, the Academy squeaked its manuscript past four ecclesiastical censors. But it was becoming increasingly difficult to suppress information that might damage traditional ways of thinking. Galileo’s discovery of moons around Jupiter showed that the earth was not the center of everything, and comets destroyed the notion that the heavens never change. The microscope was revealing a hidden (occult) “new world.”³⁸

Explorers brought news of civilizations never mentioned by Plato, the Greeks, or the Bible,³⁹ and their discoveries were enthusiastically consumed by a vast readership fed by efficient printing presses.

The modern world was just around the corner.

Modern Society

Modern society emerged when more complex forms of reasoning emerged,⁴⁰ coinciding with the development of the printing press, expanded literacy, banking, urbanization, and science. Today, societies are judged modern when a critical mass of the population enjoys the technical benefits from the cornucopia of natural science. It does not necessarily mean that a critical mass of the people has a naturalistic understanding of the world. In our own times, a president of the United States consulted an astrologer. How is this possible?

I was recently in a boutique shop specializing in fancy soap, waiting for friends to finish their shopping. While I was staring at a prominent sign that announced “We do not use chemicals in our soaps,” a young clerk asked if she could help me. I inquired what their soap was made of, if not chemicals. She replied, “Well, we use baking soda—” to which I blurted out, “But baking soda is a chemical!” Her astonished reply was, “It is?”

Her response shows how little knowledge about science one needs to live in a scientific society, or even to become president. Over time, the progress of science has enveloped us so thoroughly that we often fail to understand that it exists invisibly, like a window through which we view a landscape. Richard Feynman41 lamented that “The value of science remains unsung by singers, so you are reduced to hearing not a song or a poem, but an evening lecture about it.”

Public-health officials and scientists who help us now live longer than ever before are still viewed with suspicion and fear by some. Astounding numbers of people object to such obvious protections as immunization, fluoridation, and food preservatives. This is not to deny that many chemicals have caused serious pollution and poisoning. However, opinions about the chemicals that protect us from disease and starvation are often driven more by fear than fact.⁴²

The National Council on Science and Health recently produced a “Holiday Dinner Menu” that identified all the naturally occurring chemicals in common foods that are known to be carcinogenic in rodents. The menu is an impressive display. Their purpose was to show that 99.9% of all chemicals that people eat are naturally occurring. The issue is not so much which carcinogenic substances we have been exposed to, but how much. However, it should not be a surprise that some people now claim they are made ill by low levels of minor toxins following brief periods of exposure and by chemicals with no know toxicity.

Multiple Chemical Sensitivity

Individuals who believe they are suffering from low exposure to poisons are said to be suffering from Multiple Chemical Sensitivity. Multiple Chemical Sensitivity syndrome is known by about 20 different names such as: environmental illness, multiple-chemical hypersensitivity, immune-dysregulation syndrome, ecological illness, and chemical AIDS. However, several scientific organizations have expressed doubt about this syndrome, including the American College of Occupational and Environmental Medicine, which suggests that the term “idiopathic environmental intolerance” more accurately reflects the current state of knowledge.⁴³

The problem is that no known science connects a specific chemical or chemicals to the symptoms reported by patients. General medicine abandoned appearance-based classifications more than a century ago.⁴⁴ However, psychiatry has continued to name disorders without any certainty of their underlying etiology.⁴⁵(xxiii) Once a set of symptoms is named, clinicians are free to rush in with theories and treatments.

What are the symptoms that grip those with Multiple Chemical Sensitivity? The symptoms range widely over multiple organ systems, including systemic (chronic, overwhelming fatigue), neuropsychological (confusion, short-term memory deficits, sudden sleepiness), musculoskeletal (muscle spasms, pain), lower respiratory (difficulty breathing), upper respiratory (congestion, sore throat), and gastrointestinal (bloating, cramps, indigestion).⁴⁶

Physicians are rightly confused if an individual’s symptoms change or get worse over time, especially after exposure is ended. Further, some individuals become so incapacitated that they become sicker following minor exposure than those exposed to known toxic levels. Even then, the pattern of sickness is wrong: no known science connects a specific chemical exposure to the identified symptoms.

Further, similar symptom patterns are described by some patients labeled as victims of chronic fatigue syndrome, fibromyalgia, neuropathic pain, reflex sympathetic dystrophy, and other nonspecific disorders.

All of these syndromes are similar in that they have a variable list of symptoms that cannot be understood as arising from a single disease process. Instead, multiple organ systems are involved for which there is no understandable patholophysiologic process. Is there a specific disease here? Twenty patients with Multiple Chemical Sensitivity were exposed to a variety of chemicals in an environmental chamber.⁴⁷ Each exposure was accompanied by an olfactory mask in a double-blind study. Subjects demonstrated no reliable responses when challenged by 145 chemicals and clean air. Their symptoms could not be attributed to the chemicals that they believed were responsible for their distress.

About two weeks after exposure to a toxic chemical, a worker developed a vocal-cord dysfunction and a chronic-cough syndrome that resulted in frequent emergency-department visits. Doctors urged him to address the emotional issues that surrounded his disconcerting symptoms, but he refused. A variety of medical specialists all noted the behavioral aspects of his symptoms, and he responded by claiming that a variety of chemicals could now trigger his coughing spells. For example, he said that a bright-red poinsettia caused him some difficult in a doctor’s waiting room. When that plant was brought into the exam room, within one second he responded with “a partial collapse of the entire trachea (to the level of the carina) consistent with the extreme intrathoracic pressure generated by the patient.” The plant was quickly removed, and his symptoms resolved within two minutes. Although several clinicians taught him how to control his coughing episodes, there was little evidence that he ever used these techniques.e

When evaluated, patients with Multiple Chemical Sensitivity often seem indistinguishable from patients who are simply depressed except in the way that they conceptualize and attribute their concerns. These patients view their symptoms as the result of biologic processes. They reject psychologic processes and labels, just as victims of tarantism rejected the idea that religious and sociopolitical factors influenced their dancing. However, it is easier to see the external influences on older symptoms, like dancing mania, because the current symptoms, like those of Multiple Chemical Sensitivity, seem so understandable in our chemically crowded environment.

Disorders with a Tenuous Organic Basis

Since the earliest medical writings of the Greeks and Egyptians, some symptoms were understood as being influenced by emotions.⁴⁸ For example, people knew that swooning was not part of a disease process, yet when a person swooned, it seemed appropriate to call a physician. Such symptoms were usually described as hysterical or hypochondriacal.

Unfortunately, the brush of hysteria became so broad that it painted almost everyone the doctor thought complained too much.^49,50 Hysteria also came to be confused with personality disorders.^51,52 Even worse, several studies showed that patients described as hysterics, when evaluated more carefully or followed over time, often had neurological, cognitive, or structural disorders.^53–55 Indeed, we now know that many of Freud’s pivotal case studies were very likely not hysteric or neurotic but rather individuals with medical conditions upon which he built psychiatric theories.⁵⁶ Eventually, hysteria was split asunder to form a variety of somatoform disorders such as Somatization Disorder, Conversion Disorder, and Hypochondriasis.⁵⁷ These patients are also discussed from the perspective of illness behavior or abnormal illness behavior,^58–61 and from the role of sociology of the sick.^62,63

Although many organic illnesses can have variable presentations, the symptoms of interest here are those influenced by the expectations, values, and belief systems of the society in which they flourish. These symptoms are so congruent with our perceptions about how the world works that it is difficult to perceive this influence except in historical perspective. Even more, these symptoms are particularly compelling for the patient and the doctor as they interact in the clinical setting.

In 1778, Paris was a magnet for charlatans. The gay and frivolous aristocracy embraced any new sensation. They cared nothing for the scientific experiments on the lodestone by Williams Gilbert but were instead enthralled by Mesmer’s animal magnetism. Mesmer’s patients were convinced that their convulsive responses proved his power, and Mesmer became unshakably convinced that his theories were correct.

Through a series of careful studies, the commissioners appointed to investigate animal magnetism determined that everything observed could be explained by imitation and imagination.⁶⁴ The effects were authentically experienced by Mesmer’s patients, so the operations of imagination and imitation were opaque to patient and magnetizer alike.

However, about 65 years after the commission’s report, French physician Victor Burq discovered quite by chance that he could disrupt the mesmeric state of his subjects by the application of copper, which had a tendency to burn, irritate, or repulse.⁶⁵ In contrast, gold and silver were generally soothing. He reasoned, then, that copper might disrupt the pathologic anesthesia that characterized many hysteric patients. Burq was amazingly successful in his treatments, and he had additional opportunity to try copper bracelets for the relief of spasms and cramps on victims of the cholera epidemic of Paris in 1849.

When the success of Burq could no longer be ignored, Jean-Marie Charcot was assigned to investigate his claims. Although Charcot was a brilliant clinical observer who established the modern foundations of neurology, he was unprepared for the psychological complexities of investigating “hysterical” symptoms.

Goetz says that Charcot’s “methods and curious reliance on magnets, electricity, and metals today seem exotically paramedical.”⁶⁶(111) Charcot’s main biographer, Georges Guillain, merely says that Charcot’s work in metallotherapy was “a slight failing.”⁶⁷(165) Both avoid describing the woeful experiments and treatments with metals that Charcot conducted. Most biographers completely ignore Charcot’s early hypnotic work because it is so bizarre by today’s understanding.

This “slight failing” in metallotherapy was only the beginning of some serious attributional errors of Charcot. For example, Charcot conjectured that there must have been some trauma behind certain symptoms, perhaps even some forgotten trauma. Careful historical work by Borch-Jacobsen⁶⁸ shows that Charcot launched the expectation that an event of trauma would be followed by amnesia.

Before Charcot’s experiments, the patients remembered quite clearly the psychic or mechanical shock that triggered their hysterical paralyses and attacks. After, they would tend not to know the cause of their symptoms anymore: the era of “dissociation of consciousness” and of “repression” had begun.^68(22–23)

Charcot, like Mesmer before him and Freud after, observed the responses of his patients and believed he had all the evidence needed to confirm his theory. This “amnesia to trauma” has been eagerly reified into pathology by an army of psychotherapists who can easily create more problems than they solve after improperly making the diagnosis of dissociative identity disorder^69,70 or posttraumatic stress disorder.^71–74

The diagnosis of the patient in my previous case example was described by one physician as a conversion disorder, and he suggested that the onset of the symptoms was probably the “trauma” of his initial chemical exposure.

Later physicians dropped the quotation marks around trauma, and one suggested that his chemical exposure “may well have constituted sufficient trauma for him to have an occupationally related post traumatic stress syndrome.” The insurance company then paid a psychiatrist “to assist him in processing the trauma of his [chemical] exposure and the severe impact it has had on all aspects of his life.” In fact, the psychiatrist’s records show that he had merely listened to the patient complain about his life and the insurance company. Meanwhile, the array of medical specialists noted that the patient stopped using the behavior controls that he had been taught and seemed uninterested in trying new methods of management. This patient now had an intractable Multiple Chemical Sensitivity syndrome and a posttraumatic stress syndrome, both of which he attributed to past external events beyond his control.

What is this process that creates new symptoms out of thin air? In the early 1950s, Martin Orne demonstrated how two people working together can unknowingly create a false reality. Through a series of cleverly designed studies, Orne gathered evidence for this phenomenon. For example, he showed that age-regressed hypnotic subjects could recite earlier-learned but now forgotten poetry, recall details of their life from the first grade, and draw pictures illustrating this age regression. However, for the most part, these productions were “extremely deceiving” hallucinations.⁷⁵(221)

Subjects experienced their situations as completely authentic, and clinicians were convinced of their reality because the subjects respond with complete sincerity. In subtle ways, each side of the dyad was deceiving, or misleading, the other.⁷⁶ Both were unaware of the implicit clues sent by the hypnotist, and both failed to realize how faithfully the subject responded to these expectations.f The hypnotist was unaware of how much his own theory drove the interaction as subjects integrated the hypnotist’s expectations with their own past experiences and expectations. The broad principle here was outlined by Orne in a seminal study called “The social psychology of the psychological experiment,”⁷⁸ which became one of the three most cited papers in American psychology. The lessons now seem forgotten, but the implications remain enormous. Inquisitor and witch, charlatan and dupe, scientist and subject, clinician and patient are each influencing each other, creating false realities in ways that we have yet to appreciate.⁷⁹ We must be more sensitive to these possibilities of self-deception in the assessment and management of patients who report that they have Multiple Chemical Sensitivity and similar disorders in which symptoms emerge secondary to a belief system.

Assessment and Management of Multiple Chemical Sensitivity

If clinicians and patients can lead each other into unintended error, then the health-care professionals must attend to this possibility from the beginning. For example, in the assessment interview, clinicians must not provide cues about the symptoms of interest because, sure enough, those symptoms will often emerge. These early assessment sessions are particularly critical because patients will be acutely sensitive to any hint that the clinician will dismiss their problems as emotional. The patient’s preference for biological over psychological explanations is not simply a personal partiality, like preferring country over classical music. The patient believes he experiences symptoms as the result of chemical exposure, and any attempt to change the patient’s mind will be met with disbelief, distrust, or disdain. Knowing the research about Multiple Chemical Sensitivity is not sufficient. In fact, knowing the research will more likely put the clinician and patient at odds with each other. This divergence in attribution sets the stage for therapeutic failure.

On the other hand, endorsing the patient’s perception can also have negative consequences. The nocebo effect—the worsening of a condition due to negative expectations—is induced by careless words.^80,81 Even ordering laboratory tests can reinforce the notion that the doctor knows something is wrong. The clinician must understand the potential for disease but resist the temptation to evaluate and treat every complaint. The task here is to manage the patient’s fear while not being blindsided by an unexpected problem. In this regard, the Royal College of Psychiatrists offers valuable suggestions for interview and management.^82,83 The current scientific knowledge tells us more about what will not work than how to be helpful. Nevertheless, even here, a commitment to the scientific enterprise provides some guidelines. For example, patients must not be abandoned to quacks.

A mother brought her developmentally delayed child to a quack at the referral of a medical-school professor. The quack convinced the mother that her son’s behavioral problems were the result of environmental poisons, and he prescribed about 23 different medications and supplements for the mother to administer. (Fortunately, most were harmless.) An emergency-department physician reported the mother to Child Protective Services as a case of Munchausen syndrome by proxy, and the state tried to take her child away—for following her doctor’s orders. The professionals who wanted to punish her seemed unable to understand that her intention was to help, not hurt, her child.

Quacks have been successful in recruiting patients because, as de Francisco⁸⁴ noted, physicians treat disease, but quacks treat doubt and fear. Sadly, a variety of practitioners, activist organizations, and entrepreneurs have turned sections of the health-care-delivery system into a marketplace. To keep patients in traditional settings, clinicians and third-party payers may need to make changes. Assessment and management are time-consuming, and an array of health-care professionals may need to collaborate in new ways.⁸⁵ Some of these patients are in hard times; their doubt and fear need attention. How, then, should clinicians who practice evidence-based medicine approach their patients? The scoffer will disbelieve that chemicals cause Multiple Chemical Sensitivity. But the skeptic—the scientific practitioner—will doubt his or her own attributions as well. Medicine and science move forward by searching for evidence that contradicts the diagnosis (the hypothesis) that seems most probable at any given time. I believe this doubt and openness create a cooperative assessment enterprise. Doubt, when it sparks curiosity, should not immobilize but energize the adventure. It is here that clinical knowledge and judgment are most important, so that the physician can consider all possibilities while rationally deciding what symptoms to monitor and what tests to administer. All the while, patients must have confidence that physicians are on their side.

The first task is to understand the patient’s distress. How long have symptoms persisted? How widely do they interfere with life? How frequently do they occur? This review of duration, intensity, and frequency suggests the pervasiveness of the disorder. It is also important to know the patient’s belief system. Lees-Haley and Brown⁸⁶ have provided a comprehensive review of influences and biases that create belief about chemicals. Moreover, the patient’s self-report is influenced by a spectrum of biases. This report should be compared with past medical records, not to entrap the patient but to understand the evolution of symptoms.

Some sources of influence, like internet chat groups, help the patients avoid displaying symptoms that appear functional while encouraging those that appear more organic. This ever-escalating complexity underscores the importance of careful history gathering.

A bank executive with Multiple Chemical Sensitivity experienced such loss of energy that he no longer had the strength to do his desk job. His physician endorsed his disability claim, but the insurance company wanted a psychiatric evaluation. The psychiatrist asked me to administer neuropsychological tests, because he believed the man had seriously deteriorated mental function. In my interview, I discovered that this man was spending six hours each day managing a Web site for people with Multiple Chemical Sensitivity. Once I showed interest, he began discussing the scientists and research centers around the world where a breakthrough on his disorder was imminent. Neuropsychological assessment was obviously unnecessary.

Further, the complexity and costs soar when these cases go into litigation. A health-care technician became ill from the fumes of a remodeling project near her work station. Her primary-care physician was part of the same system that employed her, and he approved an extended leave for her in an attempt to avoid the appearance of prejudice. Efforts to return her to work were unsuccessful, as she fell ill from an increasing array of environmental chemicals. She filed a lawsuit that consumed an enormous amount of time on the part of hospital administrators, environmental experts, toxicologists, consultants, and attorneys. Then it was discovered that the onset of her complaints coincided with counseling about her work performance. Covert surveillance showed her to have been active at a time she said that she was too sick to attend an examination. An earlier, more careful assessment of the context of her complaint might have averted this extended, expensive, and useless chase for elusive toxins in her environment.

Multiple Chemical Sensitivity can present simply, but with most persistent cases, other psychiatric diagnoses are apparent, such as depression or somatoform disorders. Lipowski⁵⁹ suggested that patients suffering from somatoform disorders tend to experience and communicate somatic distress and symptoms unaccounted for by pathological findings, to attribute their symptoms to physical illness, and to seek medical help for them. In seeking help, some individuals seem driven or overwhelmed, almost as if searching for someone to take care of them. Reassuring the patient that nothing is wrong will only raise anxiety and ensure that more dramatic symptoms will follow. It is often difficult to provide consolation or reassurance because the patient overvalues the idea of bodily dysfunction.⁸⁷

Clinicians must sort the psychodynamics of a somatoform disorder from the psychological struggles created by illness. Not all patients with Multiple Chemical Sensitivity will have these somatoform dynamics; however, when they are not clearly evident, it is appropriate to monitor closely for medical, neurologic, neuropsychologic, and other psychiatric possibilities.

Several studies have shown that somatoform disorders coexist with personality disorders at rates as high as 60 percent.⁸⁸ These personality disorders complicate assessment and management, especially during periods of acute distress.

In the middle 1990s, many women with breast implants believed they were being made sick because the inserts were toxic to them. A defense attorney asked me to review the records of a 36-year-old woman involved in litigation. Her six volumes of records revealed a wide range of medical problems before the age of 23 that would easily qualify her for a diagnosis of somatoform disorder. Over the years, she received such Axis II diagnoses as borderline personality disorder and passive-aggressive disorder. Her records revealed blatant misrepresentations, drug-seeking behavior, and denial of personal problems, while involved in serious marital strife. In the midst of this chaos, she obtained her breast implants. All of her medical complaints continued exactly as before; however, now these problems were blamed on her breast implants. The records showed a 15-year history of attribution errors about the source of distress in her life.

A comprehensive list of problems can protect patient and provider by highlighting the spectrum of troubles in the patient’s life, thereby avoiding the seductiveness of simple solutions. Rushing into treatment is often a short path to failure. Without patient readiness, treatment is unlikely to be successful. I leave the discussion of treatment of Multiple Chemical Sensitivity to other authors, but my view is that most clinicians fail because they become impatient with the difficult task of long-term management.⁸⁹ Using this context, the clinician can begin sharing information and offering services with the intent of help instead of hassle.

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About the Author

Loren Pankratz, PhD, Clinical Professor, Department of Psychiatry, Oregon Health Sciences University.

Correspondence: Loren Pankratz, 1525 SW Palatine St., Portland, OR 97219 (email: loren.pankratz@comcast.net)