Decline of neuresthenia, January 23, 1992

Moderator: University of Iowa History of Medicine Society. January 23rd, 1992. This evening's speaker is Professor Tom Lute of the University of Iowa's Department of English. Dr. Lutz' topic this evening is the decline of neurasthenia. Tom Lute: I guess a couple of things. I hope the bridge is in better shape than most of the bridges around the country, right? They're all falling down. I'm afraid that I don't right away try to define neurasthenia. I don't define it in the book. So I figured why start now? But the ... this is a piece that's going to appear in a volume of the American Psychological Association. The APA is putting out a volume commemorating its 100th anniversary. I'm not sure this does a very good job of commemorating anything in the history of psychology, but it does talk about the history of psychology a bit. But the fact that it's in that volume may account for a lack of critical edge here and there, or a softening of the critical edges. I rely a little bit on knowledge of neurasthenia and at the same time I try to slip in what people would need to know if they've never heard of it before. It's a disease that was epidemic in certain circles in the turn of the century. It started in the late 1860s and was dying out in the 1920s, which is the subject of my paper. And I think there's enough in the paper to explain the rest of it, but we'll see. It's also ... I've cut it about in half to give it as a talk tonight, the paper. And I left out a lot of the medical journal quotes, which I think are a lot of fun but weren't absolutely necessary to move the argument along. And I think I left out most of what's very convincing about my argument. So if you're not convinced, trust me. It should take about 40 minutes I think to get through this. So feel free to take a snooze in the middle. I start with a quote from a book by Langdon Mitchell called Understanding America. Langdon Mitchell is the son of S. Weir Mitchell as I'll explain. The quote is, "A false conception of what makes for a good life is the main and active cause of our great American malady of boredom." In 1927, as his father had before him, Langdon Mitchell made a stab at explaining our national disease to get at the roots of what is wrong with our America with the life we lead. His father, S. Weir Mitchell, the physician famous for inventing and propagating the rest cure for nervous ailments, had concluded in his widely respected writings that modern life wore people down. People always relate to that. Along with other physicians at the end of the previous century, Mitchell believed that new modes of transportation, innovations in gender roles, what we might now call the information explosion, and the general pace and busyness of modern life chafed against peoples' nervous systems, leaving them worn and torn. Not just the doctors, but artists, intellectuals, editors, journalists, and their audiences saw their world as moving too fast. The demands of everyday life were so multifarious and knowledge, commerce, cities, populations, immigration, technologies were all expanding and multiplying so quickly that the average successful man and his wife were ... that's sick, I guess ... were all necessarily exhausted often to the point of illness. Nervous energy or nerve force needed to be spent in so many ways and in so many directions went the medical explanation that nervous bankruptcy was the increasingly common results. Nervous bankruptcy or nervous mania as it coined in the late 1860s was known throughout the west as the American disease. Americans had it more and it was a typically American disease even though it was all throughout Europe as well and in South America to a certain extent. The logical prescription Weir Mitchell argued, was rest, a vacation from the out sized demands of modern civilization. If over exertion and over work were the culprits, then rest and leisure were the cure. Thirty years after the height of his father's career, Langdon Mitchell came to the opposite conclusion. The problem wasn't over work. The problem was too much leisure and its concomitant, boredom. "Our leisure hours have no good meaning for us," Langdon Mitchell wrote. "We meet them as the man meets a dun or the shadow of death," he declared, extending the metaphor of bankruptcy. "Historical events have deprived the American of much that he should and once did possess. All he knows is that his life is empty and he feels sad. The only salvation," the younger Mitchell argued, "laying the production and reception of high culture and in work. We must look into our civilization," Mitchell stressed, "into the moral wellbeing that we try to embrace in the word culture." The Mitchells, father and son agreed that the march of progress has got people feeling blue. But for Mitchell pair, the culprit's over civilization and for the son it's that there's not enough civilization. Where Mitchell forbade his patients literature and argued that only the healthy could withstand a passion for arts and fictions, in his rest cure you weren't allowed to read or write as the most famous picture of this in the Yellow Wallpaper makes very clear, and were spoonfed a milk by a nurse so that you wouldn't waste any energy lifting ... spoonfeeding yourself I guess. His son recommended the excitement and stimulation of fiction and of a varied cuisine, and fiction in the other arts as cures for boredom and sadness. The father warned of the dangers of overwork, while the son praised the happy workers of Whitman, the anonymous ambitious farmers and tradesmen of American, the energetic self-made politicians like Washington and Lincoln. In the space of a generation, excitement, absorption, and work, passion, art, and culture had moved from being causes to being cures of our national maladies. Any number of explanations might be offered for these reverses. The Great War had obvious impacts on everything from the place and conduct of American and international affairs to the structure of modern memory and consciousness. And for those of you who know the historiography of this period you'll catch some of the catchphrases in this next paragraph. Bureaucratic and industrial expansion and standardization led to an intensification of the rhetoric and practice of individualism and related glorification of individual experience. The rise of advertising and its effects, including the institution of and about culture of commerce or visa versa, the rise of a business culture and the concomitant cultural centrality of advertising necessarily repositioned art and literature. As the authorities recognized by earlier generations, those of the church and state for instance, lost their legitimacy in some circles. Artists and intellectuals attempted to fill the void of cultural authority with their own threats and promises. Langdon Mitchell's belief that art was a cure for inadequate civilization marks him as a quintessential modernist, a typical exponent of the idea that high culture is a motive force rather than a teleological flower of progressive civilization. He's typically modern in rejecting his father's staunch Victorian faith in the vast height of his cultural plateau and in recasting the high civilization of American Europe as barbaric evidence by the devastation of the Great War. And he's typical modernist because he exalts high culture as a moral and aesthetic cure for the degradations of mass culture. Victorian intellectuals and professionals ask what the impediments to progress of civilization might be and what threats individual backsliding of various kinds might pose to that progress. And Neurasthenia was a medical theory related to those questions. They had read their Plato and Gibbon and given they were aware that republics and empires could decline as well as rise. In the years after the Great War, the question just seemed to be whether we had a real civilization at all. And if so, was any of it worth saving? The essays collected in Harold Stern's Civilization in the United States, which was as book much talked about throughout the 20s tended toward the negative for instance. And Langdon Mitchell uses that text as his exhibit A and the pessimistic new novelists as exhibit B for what he calls our current malady. Despite this central and ongoing debate about civilization though, it's clear that the discourses the younger Mitchell had available for describing a national disease has themselves been innervated. When the older generation had warned their fellow citizens about the dangers of American nervousness, they could call on a medical theory that made explicit the profound threats to health, life, sanity, and civilization that accompanied scientific technological and social progress. All the younger Mitchell could complain about was a vague dissatisfaction, a worrisome, but finally far from alarming ennui, a disease without distinction. Physicians like the elder Mitchell were professionally respected, financially rewarded, nationally known and culturally authoritative on issues that to us look far removed from their punitive areas of their expertise. Mitchell was a neurologist, a nerve specialist who began his career studying the effects of gunshot wounds right after the Civil War. Laced through his books on nervous illness are what he called after Huxley, lay sermons on everything from racial difference, sexual morality, marriage relations, literary excellence, and the separate and converging responsibilities of labor and capital. Mitchell was in the position to give these sermons, not just because of the prestige of his expertise, but because the theories of nervous disease which he and other neurologists developed during the last decades of the 19th century were themselves imbued at every level with the ... they have been imbued with something. Where am I? The imbue every level by cultural beliefs and norms. He could be sure of his audience who either lived or envied some version of the ideal American late-Victorian, elite, WASP lifestyle. And the underlying assumptions of that lifestyle were also the assumptions governing the theory of neurasthenia, that women were more sensitive than men, Anglo-Saxons more aware of their surroundings than Asians, Protestants more refined than Catholics, brain workers more fastidious than workers, and whites more intelligent than blacks all has the status of medical facts. For instance, they all helped explain, among other things, why WASP brain workers suffered from the disease more than any other group. Since one of the causes of women's illnesses was their rejection of traditional roles in favor of too much brain works like college or social work, Mitchell had an obligation as a physician to explain to women the health benefits of household management and of child rearing. And since men could lose their nerve force through an unmanly overindulgence in such things as aesthetic experience, it was Mitchell who claimed that the literary monthlies were getting so feminized that they were soon going to begin to menstruate. Physicians had a responsibility to proselytize for strenuous, old-fashioned masculinity. As the practice of neurology became more specialized in the decades after the turn of the century, more narrowly defined and disciplined, cultural explanation and cultural criticism became seen as tainted by unscientific moralizing and physicians began to do their damnedest to avoid them. Sinclair Lewis' Arrowsmith, a novel from 1925 most clearly represents the disdain scientists and honest doctors had for public sermonizing. And that novel, the clownish pitch-man, Dr. Pickerbaugh, who goes in public and gives speeches about the moral benefits of not spitting in the street and of the saintliness of hygiene. He sermonizes at the expense of looking foolish at playing the clown, of being the clown. Pickerbaugh as it turns out, is not actually a practicing physician. He's a public health official, which itself was a new medical specialty. It's journal, Mental Hygiene, the central journal in that field at that time. It was started in 1916. It's only certain areas like the mental hygienist that continued to argue the morality of medical news. In addition, some schools of medicalized psychotherapy retained the earlier neurologists' emphasis on culture, as did many academic psychologists. And it is to them that the mantle of preachment and prophecy passed, easily seen in Freud's tracts of the 1920s and 1930s on the history and future of civilization, art, and religion. John B. Watson, famous as the father of behaviorism, and I guess of pop psychology, and of the consulting fee ... is that right, Mitch? I don't know. Wrote an immensely popular child rearing manual that promised a better world through scientific parenting, and many lesser known psychologists felt comfortable propounding moral and cultural theory. Psychologists thereby acquired the authority on cultural issues formerly enjoyed by the neurologists with all it's aura of authenticity. As Frederick Lewis Allen remembered at the end of the decade, "Of all ..." Allen wrote a very popular history of the 20s right away in the 30s. "Of all the sciences, psychology was king." Freud, Adler, Young, and Watson had their tens of thousands of votaries, intelligence testers, invaded the schools in quest of IQs. Psychiatrists were installed in business houses to hire and fire employees and determine advertising policies. And one had only to read the newspapers to be told that psychology held the key to the problems of waywardness, divorce, and crime. And at the same time, the neurologists were re-figured in the popular presses and also even in the medical journals as myopic, kind of nerd ball scientists out of touch with daily life. In 1920, JW McConnell, MD in trying to explain why many general practitioners avoided neurology altogether invoked this current stereotype. "Neurology is regarded as an unknown land, the exploration of which should only be attempted by high brow individuals who wear heavy spectacles, who have stooped shoulders, and who consider the greatest pleasure in life to the be the changing of fluids on the specimens in their laboratories." The psychologists had moved from a very similar position. That is from being an egghead researcher to being a scientific expert offering advice about everyday life. And the neurologists had gone the opposite route. As any schematic analysis does, this of course oversimplifies a complex field and obvious there were some psychologists in the 90s who were arguing for applied psychologists. And there were some neurologists in the 90s, 80s, and 90s who thought that neurasthenia was quackery. And likewise, there were still neurologists in the 20s prescribing vacations for a fairly hefty fee, and there were quite a few psychologists who were arguing that applied psychology was way too early in the history of the science. But the overall ground had shifted significantly. And one clear sign was the fact that the disease that Mitchell had helped make into an epidemic and which had helped make him famous and wealthy was being dismantled and abandoned by the medical profession. At the turn of the century, neurasthenia was still a raging epidemic and nervousness still a prime category of personal and cultural explanation, which is what I talk about in the book. It's like I'm on Johnny Carson. But by the 1920s, books continued to pour off the presses, giving outlines of neurasthenia and related illnesses and recipes for cure, but they were regularly derided in the scientific journals. Here I'll skip over a series of examples of that. The scientific journals reviewed these books apparently just to make fun of them. The first and most serious charge against neurasthenia was that it was simply a cover for ignorance. W.C. Ashworth is one of a few examples, argued that neurasthenia is a sort of blanket term to cover our ignorance of some functional nervous disorder which we find difficult to diagnose without careful and painstaking examination. M.D. Clayton, who I guess would be M.D. Clayton, MD, asked the medical question, "When is the diagnosis of neurasthenia justified?" in 1926, and concluded that the answer was never. "This one diagnosis," he writes, "has been allotted greater use and greater abuse than any other diagnosis known. It's my opinion that the diagnosis has served its purpose, outlived its usefulness." And denunciations of the terms semiotic vagrancy became overtime the formulaic opening for any essay on neurasthenia, whatever the writers find the conclusion. Even if a writer wanted to defend a certain use of neurasthenia, they started by saying, "Well, everybody knows that it's overused and used improperly most of the time." Peter Bassoe in the Wisconsin Medical Journal wrote, "Any physician who uses that term should get a little bad taste in his mouth every time he uses it, and not think he has done anything brilliant when he calls a case one of neurasthenia. It must be understood that it's just a general descriptive term that includes a great many dissimilar cases which have certain features in common. If we use it in that spirit, then we should go on and improve ourselves." This conclusion that neurasthenia was a description of a complex of symptoms that might indicate any number of different diseases was the middle road to its abandonment. Medical writers who adopted this middle road did so by claiming it not as a disease, but as a reaction. Clarence May writing in the New Orleans Medical and Surgical Journal in 1925 agreed that nervousness is not a separate and distinct disease entity. It's a type of reaction to physical and mental maladjustment, almost invariably preventable and curable. Some writers were less successful than others at walking this rhetorical tightrope. CF Neu in the medical record, seemed to worm his way into a corner and settle there, however uncomfortably. "The [inaudible 00:19:00] should be restricted to an enfeeblement or fatigue neurosis, a primary fatigue neurosis, it's cardinal characteristics being an inordinate sense of physical or mental fatigue, or both, a difficulty of concentration, of attention and application to work, a sense of pressure in the head, an irritability of the spine, various paresthesias, and more or less disturbance of function of the various visceral organs, all being more or less closely related to psychogenic factors." It's more or less is the narrowing of the category, with plenty of clauses to keep it wide. The move to isolate neurasthenia and psychogenic factors that New and others made at this point in the 20s imitates the Freudian succession from physiological neurology. But Freud himself had come to a somewhat opposite conclusion himself some years earlier. In an 1895 paper, Freud set up shop by making a distinction between what he called actual neurosis and psychoneurosis. The former, or the psychoneurosis being psychogenic, and therefor amenable to psychoanalysis and actual neurosis being organic and therefor the province of neurologists. The latter, the actual neurosis including neurasthenia, were not psychogenic according to Freud, and therefor not treatable by psychotherapy. Freud was interested in carving away some of the territory that the then still epidemic of neurasthenia engulfed. Rather than challenging the medical establishment's authority over actual diseases, Freud simply asserted the value of his analytic therapy for a small set of psychoneurosis. By the 1920s, Freud's influence however vague, was omnipresent in American intellectual and professional circles. The journal that had been most friendly to theorists of neurasthenia during the 19th century, the Journal of Nervous and Mental Diseases was edited during the late teens and early 20s by Smith Ely Jelliffe, Jelliffe or Jelliffe. Jelliffe, who along with William Alanson White produced major new systems of classification for diseases of the nervous system that made room for Freudian thinking. White wrote in the Journal in 1922 that, "Freud's contribution may very properly be considered of as great importance to psychopathology as Darwin's was to biology." The Journal of Nervous and Mental Diseases helped lead the campaign for the abandonment of neurasthenia in its articles and reviews ... and here I'll skip a whole series of examples of that. My favorite though is when Karl Menninger who writes in quoting a fellow physician who had said the neurasthenic state persisted in one of his writings wrote, "The neurasthenic sick! Persisted." To vitiate the category of neurasthenia made its apparent sufferers available to other diagnosis. As one doctor put it, "The neurasthenic and his neurotic associates are at the threshold of a more fair consideration." And this consideration involved new disease entities of which neurasthenic symptoms were secondary signs. For many physicians, what had happened over the last two decades, this is speaking from the position of the 20s now, was the standard ongoing process of renaming with more specificity, the same disease entities that previous physicians had seen. It was a simple case of the march of scientific progress. If the study of nervous disease had long been handicapped by the confusion of symptom and diseases, then fine tuning the nomenclature could provide an end to confusion. This implied that changing disease categories represented the process of a simple translation. I'll skip some examples of that as well. This way of thinking could cut both ways of course, for if little had changed, little advance could be claimed. 'To label a patient neurasthenic is no diagnosis at all,' Tom Williams wrote in the Medical Record in the mid 20s. But by the same token, say manic depressive is no therapeutic help either. These battles over classification were far from trivial however. Many were also turf battles, attempts at managing the competition for the therapeutic dollar. The prominent Freudian Ernest Jones in 1913 claimed at the the greatest threat to treatment of nervous maladies is the growth of what he called the menace of quackery. And he sites Christian science as his prime example. Faith healing of various kinds was all the rage in the 20s, seen in the popularity of healing of angelus like Amie Semple McPherson, who's probably the best known, but there were a whole series in the 20s. Some time tried quasi medical competitors such as homeopathist, chiropractors and hydro paths continued to pedal their wears. With the discovery of vitamins in the teens, a school of scientific nutritionists arose to promise relief from fatigue, worry, autointoxication and other ills. The physical culture movement continued to offer services that reverse the relation of [inaudible 00:24:05] to psyche promoted by the psychogenesis. This should sound fairly familiar, too. I was in California in the 80s. And relief from psychological and nervous ailments was promised in advertisements for hundreds of products from yeast, breakfast cereals, and other foods products, to detergents, appliances, automobiles, tourist spas, and of course nostrum and other over the counter medicines. Official spokespeople like Morris Fishbein of the AMA wrote denunciations of the most profitable quackeries. And Jones is, Ernest Jones is clearly mimicking the official lease of the AMA in his defense of psychoanalysis. Jones go farther in cording the the general medical profession in claims and, "In fact the new study of neurosis is destined to enhance the general importance of medicine." It's a quote. And after claiming that, "Not more than 1% of the cases usually called neurasthenic are really of this nature." Jones divides the spoils between psychosis, which should be treated by psychiatrists, and neurosis, which should be handled by psychoanalysts. He grants psychiatrists their continuing majority share of the asylum business by agreeing that they're the only practitioners capable of treating the 2/3 of asylum cases that are psychosis, that are defined at that point as psychosis. But what this seemingly generous argument about the relative provinces of the two specialties aligns is perhaps the most far reaching consequence of the disappearance of neurasthenia. Neurasthenia had become the main diagnostic category used by general practitioners for the many emotional, psychological, or nervous disturbances they were called upon to treat. As it was replaced by more specialized diagnosis, neurasthenia was de-legitimized and finally de-medicalized altogether. And the specialists effectively disposed of the general practitioner as a professional rival. Even Jones' apparent acquiescence to his fellow specialists is only partially sincere. In a move typical of the imperialism of these competing paradigms, Jones claims priority for the insights of psychoanalytic study as necessary aids to what he calls the elucidation of the previously unintelligible tangle of mental processes present insanity. And goes on to say that without psychoanalysis, the kind of ... anybody that's familiar with the early psychoanalytical literature will recognize these kind of claims. You wouldn't ever be able to understand our religion or culture or other people or yourself without psychoanalysis. And these ... what interested me in looking at this literature is the way those kind of claims are repeated not just by the psychoanalysts, which I'd been familiar with before, but also by the endocrinologists and the various other specialties as they arose, the mental hygienists, the statistical psychologists. Some of the older neurologists clearly saw this ... I'm returning to Jones' statements about psychoanalysis, as usurpation of their ground. Sir James Crichton-Browne, a leading writer on neurasthenia for decades, and the British equivalent of Weir Mitchell, acknowledged in the Lancet in 1920 what he called, "our debt to psychoanalysis for having induced us to take a more psychical and less material view of insanity." But he claimed that this was finally not new and then in so far as it was, it tended to let practitioners slight the somatic. "A successful psychotherapy still needed to be accompanied by other changes in the environment," Crichton-Browne argued, and hence, "voyages and rescuers were still important therapies." "And psychoanalysis was also," Crichton-Browne argued, "closely akin to the moral treatments of mid century, and therefore not so much as an advance as a retreat from his and Mitchell's methods." Crichton-Browne was not the only one arguing for an adherence to the old label. Two kinds of institutions continued to use the diagnosis regularly despite this deafening chorus against the disease. As might be expected, the sanitariums were the thriving business in treating nervousness, continued to go with the proven thing. Many continued to advertise in the same journals that now derided their methods. So you could have an advertisement for a rest cure sanitarium right next to an article claiming the rest cure was useless. And some sanitarium directors wrote occasional articles trying to salvation this through that notion. W.C. Ashworth, the medical director of the Glenwood Park Sanitarium in Greensboro, North Carolina argued that the real heyday was yet to come. He says, "In the progress of medical science is the provision in the schools and hospitals for the study and treatment of neurasthenia is only beginning to receive proper attention in this country." This is in 1928. All they offered however, was a repeat of the turn of the century line. The problem was a bankrupted nervous system. The treatment consisted of rest and isolation, message, electricity, hydrotherapy, forced feeding, and the use of appropriate drugs. The other institutions that continued to use the disease were veterans hospitals, L.W. Day of the Perry Point Maryland Veteran's Hospital asked, "Which authority is right, our constitutional psychopathic inferiority and neurasthenia the same? Or are we confounding one with the other? The most important difference between the two for patients," Day explains, "is that neurasthenia is compensable for veterans while the other is not. Thus, to diagnose a poor patient as having one of the new disease entities would be in effect to deny them treatment. As a result, in some veteran's clinics, even late in the 1920s, neurasthenia accounted for the majority of all psychopathological diagnosis. At the Minneapolis Clinic for instance, there were in a six year period, 2,100 neuro psychiatric cases of which 1,295 were diagnosed as neurasthenia. By the 20s there were other competitors in the field as well. Endocrinology seemed out to hold out the promise of a new set of physiological basis for what were increasingly being called emotional disturbances rather than mental disturbances. And glandular explanations threatened to wreak havoc with attempts to isolate any disturbances as clearly psychogenic, the final claim of psychoanalysts and psychologists. And at the same time, endocrinological explanations could serve as a buffer between those disease categories which were organic in the old sense, meaning that there were lesions somewhere, and those that were purely psychic or psychological. Jelliffe identified three levels of activity in the nervous system, the vegetative or physiochemical, including now the endocrines ... the sensory motor, and then the psychic or symbolic. This last being there to account for Freudianism. At this highest level only of course, Jelliffe did moralistic therapies for individuals or societies make any sense. As these three levels coexisted in mutually independent relations, the universe of nervous activity was necessarily the province of all and only specialists. And the highest of these, each of these groups argued to themselves-