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Featured Clinical Reviews

November 5, 2003

Neurasthenia and a Modernizing America

JAMA. 2003;290(17):2327-2328. doi:10.1001/jama.290.17.2327

The Civil War's surplus of amputations, gunshot wounds, and mental breakdowns gave America's newly professionalizing neurologists plenty of patients and opportunity to investigate the intricacies of the nervous system. These neurologists looked to European scientists, such as Germany's Hermann von Helmholtz, who stressed the importance of biological energy produced by digestion and presumably distributed throughout the body by the nervous system.1 Like the rest of the American medical community, neurologists struggled to find employment in a postwar health care market flooded by decommissioned physicians. By 1870, they once again found their services in demand by a growing group of people seeking medical care: seemingly healthy men and women, usually living in cities, who experienced physical pain, emotional distress, and profound exhaustion. To explain this condition, leading neurologists George Beard of New York and S. Weir Mitchell of Philadelphia combined the European science of nervous energy with a conservative suspicion of the social changes taking place in late-century America. The result was neurasthenia, a culturally oriented diagnosis that attributed mental and physical symptoms to the lack of nervous energy brought on by the stresses of modern society. Today, the illness stands as a reminder of the interaction between medicine and culture and helps illustrate how health care both influences and is influenced by developments in the rest of society.

The emphasis in neurasthenia on nervous energy makes for a vague disease by today's standards, but it allowed physicians and patients in the late 19th century important leeway in tailoring the disease to fit patients' sensibilities as well as debilities. In so doing, the disease played a role in shedding professional medicine's "heroic" reputation for leeches and cathartics and helped recast physicians as scientists and humanitarians.2 In an article first published in 18693 and later elaborated on in the seminal work American Nervousness,4 Beard argued that neurasthenia occurred when people drained their bodies of nervous energy, thereby causing organs to malfunction and allowing any number of symptoms to arise, including indigestion, fatigue, muscle and back pain, impotence, infertility, depression, and irrationality. The exact cause of this drain of energy was not entirely clear. According to Mitchell,5 two sorts of persons were particularly at risk of overtaxing their supply of nervous energy: ultracompetitive businessmen and socially active women. Mitchell thought both of these groups were unique but unfortunate products of a modernizing America.

Mitchell was not alone in noticing his nation's dramatic transformation into a modern society during the decades following the Civil War. Families migrated from the countryside to the city, men left traditional jobs as tradesmen and farmers to join the growing ranks of businessmen and office workers, women went from being mothers and daughters to also being university students and physicians, and technological developments such as telegraphs, telephones, and railroads became increasingly common parts of everyday life.6 As a diagnosis, neurasthenia commanded an intuitive legitimacy because it incorporated the anxieties that arose from these changes into the way people thought of their health. It could attribute a bank manager's headaches to his hectic schedule and the obsession for detail his job demanded. Similarly, a young woman's depression could be understood as neurasthenia brought on by the mental drain of attending a newly founded coeducational university, where she competed for grades. In many cases, diagnoses of neurasthenia attached themselves to traditional ideals, such as the restorative virtues of farming vis-à-vis the fast-paced stress of modern business or the Victorian belief in women's disposition for motherhood rather than scholarship.2 For Beard and Mitchell, neurasthenic patients were casualties of modern society whose bodies and minds simply could not keep up with the seemingly accelerated lifestyles of men and women in the latter part of the 19th century.

Medical treatment focused on mitigating the stressful impact of modernity on people's lives. Mitchell's "rest cure," reserved mainly for women, became the most famous of the therapies. Designed to increase the body's supply of "fat and blood" that was thought necessary to generate nervous energy, the rest cure kept patients in bed and on a diet of fatty foods for 6 to 8 weeks. Massages were used to minimize muscle atrophy while the attending physician counseled women on how to improve their health by embracing more domestic lifestyles.7 But not all therapy was restful. Physicians commonly sent afflicted men and their wives on rigorous "camp cures"8 amidst bucolic forests or on western ranches9 under the premise that eating roasted meat, breathing fresh air, and living close to nature would replenish nervous energy. Neurasthenic patients who could not afford surgery or the gamut of rest and camp cures could seek temporary relief through minor electrical shock treatments (usually performed in the physician's office) or patent medicines. Doctors also encouraged proactive measures such as eating more fresh vegetables, exercising regularly, taking vacations, and staying away from excess drinking and sexual activity.2

By the turn of the 20th century, neurasthenia had become a medical phenomenon on both sides of the Atlantic and neurologists found themselves sharing authority over the illness. Homeopaths, eclectics, general practitioners, and gynecologists in Europe and America tried their hand at treating the condition, each putting their discipline's own spin on the illness.10 Well-known personalities such as philosopher William James, sociologist Max Weber, social reformer Jane Addams, and feminist Charlotte Perkins Gilman experienced the illness and helped define neurasthenia in the public mind. Incorporating neurasthenic characters into fiction also became vogue, with Edith Wharton, Theodore Dreiser, Henry James, Thomas Mann, and André Gide—many of whom were neurasthenic themselves—all exerting a powerful influence over the popular understanding of the illness.11 Adding to this hodgepodge of influences, the Christian Science2 and Emmanuel movements12 gave the diagnosis a spiritualist edge by claiming to be able to heal the illness through religious faith. Encouraged by medical professionals, modeled by the social elite, contained within the pages of popular fiction, and showcased by religion, the disease became broadly defined by physicians and the general public alike. It also became ubiquitous, with one physician in 1906 likening neurasthenia to a "household word."13

Neurasthenia's expansion into public discussion sometimes took the form of reform movements that questioned the conservative cultural values Beard and Mitchell wove into their initial diagnoses. Jane Addams and Charlotte Perkins Gilman provide good examples of this. As part of a women's movement that became increasingly influential as the 19th century came to an end, Addams and Gilman challenged the strict gender roles advocated by Beard and Mitchell. Through speeches and her best-selling account of the settlement house movement, Addams urged the growing ranks of young college women to avoid neurasthenia by dedicating themselves to helping the urban poor. Social work, she argued, would allow them to escape the neurasthenia-inducing doldrums awaiting those who followed Victorian expectations and sequestered themselves within the home.14,15 Gilman believed American housewives followed out-of-date and inefficient work schedules that caused a needless waste of nervous energy. She suggested improving the situation by embracing modernity, redefining women's work, and managing housework along the most up-to-date business models so that women would have the same economic freedoms as men.16,17 In effect, within 30 years of neurasthenia's debut as a diagnosis, Addams and Gilman sought to reverse Beard and Mitchell's conservative cultural message by reframing traditional sensibilities (eg, rigid Victorian gender roles) as the cause of poor health, not the cure.

As Addams, Gilman, and their contemporaries redefined neurasthenia according to their personal sensibilities, the diagnosis grew unwieldy, lost much of its practical use, and found itself in need of further refinement. Physicians and the general public began to offer diagnoses for more narrowly defined ailments. For instance, if symptoms targeted the heart and chest, De Costa syndrome might be diagnosed.18 Soldiers during World War I came down with "shell shock," "soldier's heart," and "effort syndrome"—all neurasthenia-esque conditions that had no obvious organic cause but needed to be distinguished from the general neurasthenia commonly associated with overworked businessmen and educated women.19 As early as 1904, neurologist Charles Dana argued that the condition had become too broadly defined and should be phased out in favor of more specific diagnoses adopted from psychiatry.20 Sigmund Freud helped to fuel this psychosomatic shift with his Clark University lectures in 1909.2

Cases of neurasthenia reached a peak near the turn of the 20th century, and by the 1930s fewer and fewer physicians were diagnosing the disease.2 There are a number of explanations for this decline, including modern medicine's abandonment of the "nervous energy" model of health and the rise of Freud's psychoanalysis as a way of explaining and treating psychosomatic disorders. Equally important seems to be neurasthenia's heavy reliance on cultural explanations; developments seen as dramatic and potentially unhealthy a half century before—such as urbanization, the growth of office work, and women's increased participation in society—became more commonplace and were less frequently thought of as unhealthy. Ultimately, neurasthenia fell victim to its own widespread popularity as a cultural phenomenon that made it overly broad and no longer useful to a medical profession increasingly concerned with narrow diagnoses.

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