Madness and society have always been closely interconnected. It is not only the view on which kind of behaviour is considered normal and which ill or even insane, that has varied through the ages: Massive changes in the way of living, such as increasing urbanisation and industrialisation, have led to a whole lot of new diagnoses, which often occurred at nearly epidemic rates. An excellent example for this phenomenon is the appearance of the "Victorian nervous invalid" in the second half of the nineteenth century. The new diagnoses of neurasthenia and hysteria were applied to large numbers of men and women who suddenly showed a variety of symptoms otherwise inexplicable for the physicians of the time. In this essay, the symptoms and treatment of both neurasthenia and hysteria are briefly introduced, and possible reasons for their sudden and frequent occurrence are presented, including the idea of "degeneration" as a possible cause of mental illness. Moreover, a short comparison to a new diagnosis of the late 1990s, the "Information Fatigue Syndrome", demonstrates that changes in society and technology still lead to new diagnoses in psychiatry.
In the second half of the nineteenth century, the understanding of mental illness was subject to fundamental changes, since a whole new range of human behaviour was now considered fit for psychiatric discussion. The new "intermediate psychopathologies" appeared; cases of illness that did not require institutionalisation of the patient, but still called for treatment. The concept of the "neurosis" as a "non-insane psychological suffering" brought forward a new patient type: The "nervous invalid," a result of the changed living conditions in Victorian England. Progress, it was feared, did not come without a price. Indeed, nervous breakdowns became a phenomenon alarmingly widespread, and affected many famous representatives of politics, literature, and other fields. No wonder, then, that scientists of the time struggled to provide reasons for these occurrences, and came up with a new range of diagnoses. One of the most influential diagnoses that emerged during this period was, without doubt, neurasthenia.
"The term neurasthenia (nervous exhaustion) is of Greek derivation ... , and literally interpreted means lack of nerve strength."[1] Though the term had been used from as early as 1809, it was the American George Beard who helped it gain worldwide acceptance. George Beard, a nerve specialist, was the best known practitioner in a field of medicine that had only appeared recently. His work on Neurasthenia was very successful, and made him the first American to write about matters related to psychiatry whose work was also translated in other languages and published in several European countries.
"[Neurasthenia] is at once the most frequent, most interesting, and most neglected nervous disease of modern times."[2] - "[It] attacks or is liable to attack all functions and organs."[3] This latter statement of Beard's is, when strictly sticking to his definition of the illness, certainly not exaggerated. The list of symptoms he provides ("for convenience sake" in an order from "head and brain ... downwards") contains an enormous diversity of symptoms. They include "tenderness of the scalp"[4] and "sick headache"[5] as well as "frequent blushing"[6], insomnia[7], and "rapid decay and irregularities of the teeth."[8] "Hopelessness"[9] (nowadays maybe diagnosed as depression) occurs as well as several types of "morbid fear" including diagnoses still applied such as agoraphobia ("fear of places") and claustrophobia, yet also more obscure terms such as phobophobia ("fear of fears").[10]
The enormous inflation of neurasthenia symptoms in Beard's writings can, of course, simply be interpreted as the insecurity of a physician who explores new scientific ground and wants to make sure not to exclude something important:[11] "... [C]entral troubles affecting large tracts of the nervous system, or even limited tracts, are liable to have an immense array of symptoms ..."[12] Yet there is also a possibility that Beard's interest in keeping the Neurasthenia diagnosis rather non-specific and vague was, at least partly, caused by economic reasons: His patients were mostly well-off, and it was thus in his best interest to allow as large as possible a number of a certain new type of patients to fit into his scheme of diagnosis. This new type of patient suffered from vague, free-floating symptoms, but did not want to suffer in silence or to seek salvation in religion. Though doctors did, very often, not exactly know how to treat these patients, it was at least a relief to have a suitable diagnosis and a scientific vocabulary to talk about these symptoms. The definition of Neurasthenia is, thus, an example for the process of medicalisation, the appliance of new, scientific terms to describe certain types of human behaviour as symptoms of illness.
And an illness neurasthenia was: Beard made every effort to make clear that neurasthenia is a real disease: "...very many of the symptoms of neurasthenia have been regarded by men of science as imaginations of the patients ... the sufferers have simply been dismissed as hypochondriacs, just as with our ancestors cases of hysteria and insanity were shunned or dismissed as possessed of the devil."[13] It is to be viewed in this context that Beard sought the real cause of Neurasthenia in lesions of the brain or the spinal chord.[14] In the reigning cultural paradigm of the Victorian age, Beard's findings would only be accepted as "science" if there was an organic cause for Neurasthenia (following the somatic approach to mental illness). Furthermore, a purely psychological explanation might well have felt dismissive to patients, the doctor might have been understood as saying that the patient was not actually ill, but rather had a flawed character.
This latter interpretation, however, was something Beard urgently wanted to avoid. After all, neurasthenia affected America's finest: The illness was found "in nearly every brain-working household" in the northern and eastern states of the USA - but not among the 'muscle-working' classes occupied in, say, construction work or factory jobs.[15] Neurasthenics held very often responsible positions in companies or politics, and suddenly felt themselves unable to cope with the demands of their position in work and society. Among the "brain-working" patients of Beard's were, for example, a great many "professional patients", members of his own profession.[16] The neurasthenia diagnosis helped to explain the sudden breakdown of respected members of society - indeed, Beard felt that the treatment of their problems had long been neglected: The study of the "simple" organic diseases of "the poor" had consumed the majority of time and money. Meanwhile,"... the miseries of the rich, the comfortable, and intelligent [had] been [left] unstudied and unrelieved."[17]
In spite of his belief in organic causes at the heart of neurasthenia, Beard did not fail to portray some of the factors that made the illness emerge so epidemically: "... [T]he prime cause of modern nervousness is modern civilization with its accompaniments ..."[18] Neurasthenia, as Beard put it, occurred mostly, yet not exclusively, in America, and there "especially frequent ... in cities."[19] This view of a negative influence of living in cities on health was shared by many of his contemporaries: "Large cities are hotbeds in which neurosis and low morality are bred..."[20] Though Beard's focus lay mainly on the USA, he admitted that neurasthenia also occurred in Europe, the most frequently in England - interestingly enough the world's "first industrial nation", which was the most advanced country in terms of industrialisation and had experienced its vast effects on changing the society the longest.[21]
Throughout the Victorian age, there was an increased interest in economic well-being, putting an increased pressure on men to earn as much money as possible. The influence of the Darwinian notion of "survival of the fittest" on society is not to be neglected. Especially men of the time were subject to social competition for jobs and prestige; they were expected to be "leaders" - and it is understandable that many of them did not cope with the pressure. Opportunities to compensate this pressure were scarce or non-existent: After all, another belief of the Victorian age was utilitarianism, the belief in maximum efficiency, which left little room for personal freedom and feelings. "Exaggerated tension of the nervous system [so believed the Victorians] stimulates sensuality, leads the individual as well as the masses to excesses, and undermines the very foundations of society, and the morality and purity of family life.[22] Virtuous behaviour was considered essential; "sexual excess" (which in this time, already began with masturbation) to be leading to nervous exhaustion. "Manliness and self-reliance are not the qualities which adorn the impotent onanist."[23] The strict sexual morals of the Victorians further narrowed personal freedom and might well have contributed to create an irreconcilable conflict in the individual between the moral ideals he was brought up to hold in high esteem and his personal desires.
What added to the importance of the Victorian belief in nearly unfeasibly strict moral virtues and ideas was a network of scientific ideas that had, over time, been constructed around the idea of "degeneration", and that provided an ideal justification for contemporary norms. "The idea of degeneration provided a framework and a focus for knowledge about immanent natural processes in social and historical as well as biological contexts ..."[24] - "Mental illness was considered a consequence of the overuse or underuse of certain faculties," and mental health, logically enough, was the effect of their regular but moderate exercise" in concordance with the reigning norms of society" (such as "sobriety, chastity, self-improvement, and moderation in all things"). Failure to do so would lead to a degeneracy that even could be inherited to one's offspring.[25]
The French sociologist Emile Durkheim stressed (in his work on "The Division of Labour on Society") the effect of industrialisation and life in the urban society of the late nineteenth century on mental sanity. "Durkheim advanced the Lamarckian [Jean Pierre Lamarck (1744-1829), a French naturalist's], argument that the growth of the division of labor shapes the brain and nervous system of humans as they adapt to social arrangements of increasing speed and complexity ... In meeting the challenges of 'civilization' the human brain becomes 'more voluminous and more delicate,' suffering 'difficulties and privations' that less refined brains do not feel.[26] He also included Beard's concept of "neurasthenia" into his scheme of ideas, labelling it as a "lesser form of insanity" caused by "hypercivilization". Often, says Durkheim, were the sensitive neurasthenics driven to commit suicide, as they offered "less resistance" to "suicidogenic currents" allegedly inherent in human nature.[27]
So far, the discussion of psychiatric diagnoses and society provided in this essay has focused mainly on men of the upper classes, and the strictly defined role society had prepared for them. Yet it must not be forgotten that the role of women of the time was at least equally (if not more) rigidly defined. Whereas men were expected to follow their career, the role of women was a domestic one. It involved organising the household, engaging in representative and charitable activities, and bringing up the children. "Torn by the harsh realities of industrialization and the uncongenial atmosphere of Social Darwinism, nineteenth-century Americans sought refuge in a cult of domesticity which exalted Woman and Home."[28] The different role expectations led to a different diagnosis: Whereas men were, most often, diagnosed as neurasthenics or hypochondriacs, the "female malady" most often was hysteria, "... one of the classic diseases of the nineteenth century."[29]
It is hard to draw an exact dividing line between the neurasthenia and hysteria diagnoses. Both illnessess manifested themselves through an enormous variety of symptoms.[30] For example, the famous hysteric "Anna O." aka Bertha von Pappenheim, the first famous patient of Sigmund Freud (and his colleague Breuer), suffered from physical symptoms such as coughing or paralysis of various limbs, as well as from disturbed sleep patterns, visual abnormalities, hallucinations, and odd symptoms such as the temporary inability to drink water and the loss of her mother tongue German (instead the well-educated patient talked in up to five different idioms, including Italian, French, and, at most times, English). Hysterical symptoms, however, were generally more severe than those of neurasthenia: "The most characteristic and dramatic symptom ... was the hysterical 'fit'. Mimicking an epileptic seizure, these fits often occurred with shocking suddenness."[31]
When looking for possible causes for the new wave of illnesses in women, physicians very often sought the cause in a "malfunctioning of the feminine sexual organs."[32] The real reason, though, lie in the role of women in society: "Woman was inevitably tormented by the ambiguities of her position ... Her image was shot through with contradictions. Guardian of the race, yet wholly subject to male authority; preserver of civilization, religion, and culture, yet considered intellectually inferior; the primary socializer of her children, yet with no more real responsibility and dignity than a child herself."[33] Being confined to the same strict moral norms as men, women were probably even worse off, since they had even less opportunities to escape their monotonous everyday life.
Freud/Breuers' patient Anna O., for example, "... possessed a powerful intellect which would have been capable of digesting solid mental pabulum and which stood in need of it - though without receiving it after school ... This girl, who was bubbling over with intellectual vitality, led an extremely monotonous existence in her puritanically-minded family."[34] For Anna O., as for many other Victorian women, an escape into mental illness was the only way to overcome their hopeless domestic situation. "Indeed, as commentators on American society at the time emphasised, ill health in women had become positively fashionable and was exploited by its victims and practitioners as an advertisement of genteel sensibility and an escape from the too pressing demands of bedroom and kitchen."[35] To say that women deliberately chose hysteria as a "way out", however, would certainly be simplistic - though there are scholars who claim that "[i]t is certainly possible to see hysteria within the specific historical framework of the nineteenth century as an unconscious form of feminist protest, the counterpart of the attack on patriarchal values carried out by the women's movement of the time."[36]
The discussion above makes it clear that the reason for both the male and female variant of the "Victorian nervous invalid" were largely influenced by the pressures of Victorian society. How, then, one might question, would the typical "nervous invalid" of the 1990s, the so-called "information age" be diagnosed? In an article in an American magazine, the British psychologist Dr. David Lewis is cited with a possible answer: "Information Fatigue Syndrome". - "The symptoms of this epidemic ailment can include tension, occasional irritability and frequent feelings of helplessness - all signs that the victim is under considerable stress." [37] Just as with Beard's neurasthenia diagnosis one hundred years ago, "Information Fatigue Syndrome" affects solely "brain-workers" like business executives, teachers, doctors, lawyers, and bureaucrats of all sorts. Due to the immense advances in information technology over the recent years, such as the breakthrough of the fax-machine and the internet, these people feel suddenly overflowed with information. They do feel the pressure to deal with all of this material, yet are incapable to do so, particularly not under time pressure and when having to make important decisions - the results are the aforementioned symptoms. "A state of 'hyperarousal' sets in, causing 'foolish decisions and flawed conclusions' to become 'inevitable'. With the brain in 'panic mode', Lewis says, information is misread."[38]
It is as yet uncertain as to which extent the "Information Fatigue Syndrome" diagnosis will be accepted by the scientific community. Just as many psychiatric diagnoses , such as Esquirol's "Monomania" in the early nineteenth century, it might just be a "fashion" of a time, and vanish quickly. Still, this new illness demonstrates that the neurasthenia and hysteria "epidemy" in the last century certainly was not the last instance when changes in society led to new diagnoses.
[Word Count without footnotes: 2627]
Beard, George Miller, A Practical Treatise on Nervous Exhaustion (Neurasthenia) (1880).
Maryann Bird, "System Overload. Excess information is clogging the pipes of commerce - and making people ill", in Time Magazine, December 9th, 1996, pp. 46-7.
Breuer, Josef, and Freud, Sigmund, "Case Histories: Fräulein Anna O.," in Studies in Hysteria (1895), pp. 21-47.
Chamberlin, J. Edward, Gilman, Sander L., "Degeneration: An Introduction", in Chamberlin, J. Edward, Gilman, Sander L. (eds.), Degeneration: The Dark Side of Progress (1985), pp. IX-XIV.
Krafft-Ebing, Richard von, Psychopathia Sexualis (1886).
Markell Morantz Regina, "The Perils of Feminist History," in Journal of Interdisciplinary History, No. 4 (1973), pp. 649-660.
Mathias, Peter, The First Industrial Nation. An Economic History of Britain 1700-1914, 2nd edn. (London: Routledge, 1987).
Micale, Mark S, "Hysteria Male/Hysteria Female: Reflections on Comparative Gender Construction in Nineteenth-Century France and Britain", in Benjamin, Marina (ed.), Science and Sensibility. Gender and Scientific Enquiry, 1780-1945 (Oxford: Basil Blackwell, 1991), pp. 200-239.
Nye, Robert A., "Sociology and Degeneration: The Irony of Progress", in Chamberlin, J. Edward, Gilman, Sander L.(eds.), Degeneration: The Dark Side of Progress (1985), pp. 49-96.
Showalter, Elaine, The Female Malady: Women, Madness, and English Culture, 1830-1980 (1985).
Smith-Rosenberg, Carroll, "The Hysterical Woman: Sex Roles and Role Conflict in Nineteenth-Century America" (1972), reprinted in Disorderly Conduct: Visions of Gender in Victorian America (1985), pp. 197-216.
Wood, Ann Douglas, "The Fashionable Diseases: Women's Complaints and their Treatment in Nineteenth-Century America," in Journal of Interdisciplinary History, No. 4 (1973), pp. 25-52.
[1] George Miller Beard, A Practical Treatise on Nervous Exhaustion (Neurasthenia) (1880), p. 6.
[2] Beard, p. 5.
[3] Beard, p. 35.
[4] Beard, pp. 38-39.
[5] Beard, pp. 40-41.
[6] Beard, p. 67.
[7] Beard, pp. 69-71.
[8] Beard, pp. 105-6.
[9] Beard, pp. 48-50.
[10] Beard, pp. 50-67. Needless to say, the number of possible treatments Bread proposes are just as diverse as the symptoms of the illness itself. Possible medications include "cannabis indica", caffeine (Beard, pp. 192-3) and sometimes even "alcohol ... in the form of wine, particularly claret and Burgundy."(Beard, p. 201.) Maybe most notably, he says that "[t]o rely on mental therapeutics alone, disregarding all electricity, massage, and internal medication, is unscientific, and in many cases will be unsuccessful; the mind is a strong force, but it is not the only force that can be used for the control of functional nervous affections. (Beard, p. 189) This objects to both the ideas of the "Moral Treatment" of the late eighteenth and early nineteenth century, and Freud's "talking cure", the emergence of psychoanalysis brought forward at the end of the nineteenth century. Yet even though this casts a rather conservative light on Beard's work, it must not be forgotten that he contributed to the emergence of a doctor-patient relationship formerly unknown in psychiatry: Beard's neurasthenic consults his doctor by free will, other than being forced by law. The patient is rather a paying client and the doctor a professional 'caretaker'. With Beard, the physician even starts to explore aspects of the particular biography of his patients in order to find a cure (though still this exploration goes by far not as deeply as in Freudian psychoanalysis).
[11] Interestingly enough, Beard himself uses a geographic comparison to explain the novelty and uniqueness of his findings: "Neurasthenia, indeed, has been the Central Africa of medicine - an unexplored territory into which few men enter, and those few have been compelled to bring reports that have been neither credited nor comprehended." - Beard, p. 6.
[12] Beard, p. 114.
[13] Beard, p. 28. In a later chapter, there is an interesting passage on imagined and real illnesses: "In strictness, nothing in disease can be imaginary. If I bring on pain by worrying, by dwelling upon myself, that pain is as real as though it were brought on by an objective influence." - Beard, p. 112.
[14] Beard, p. 8.
[15] Beard, p. 23.
[16] Beard, p. 18. In fact, Beard's interest in the illness was partly sparked by personal experiences: Beard himself suffered from several Neurasthenic symptoms.
[17] Beard, p. 80.
[18] Beard, p. 16.
[19] Beard, p. 12.
[20] Richard von Krafft-Ebing, Psychopathia Sexualis (1886), p. 4. Though Beard does not explore the causes of neurasthenia in his first works, he, too, asserts that there is a "... rise and increase in modern times, not only of neurasthenia, but of the general nerve-sensitiveness of which neurasthenia ... is but a result and expression. A philosophic and thorough analysis of American nervousness must be a contribution to sociology of which it is a part, and will require a discussion of many questions of race, of climate, of institutions, and of social customs ..." - Beard, p. 15.
[21] Beard, pp. 24-5. The term "First Industrial Nation" is taken from the title of Peter Mathias' textbook on British economic history: Peter Mathias, The First Industrial Nation. An Economic History of Britain 1700-1914, 2nd edn. (London: Routledge, 1987).
[22] Krafft-Ebing, p. 4.
[23] Krafft-Ebing, p. 8.
[24] J. Edward Chamberlin, Sander l. Gilman, "Degeneration: An Introduction", in J. Edward Chamberlin, Sander l. Gilman (eds.), Degeneration: The Dark Side of Progress (1985), p. XII.
[25] Robert A. Nye, "Sociology and Degeneration: The Irony of Progress", in J. Edward Chamberlin, Sander l. Gilman (eds.), Degeneration: The Dark Side of Progress (1985), p. 51.
[26] Nye, pp. 60-1.
[27] Nye, pp. 62-3.
[28] Regina Markell Morantz, "The Perils of Feminist History," in Journal of Interdisciplinary History, No. 4 (1973), p. 649.
[29] Carroll Smith-Rosenberg, "The Hysterical Woman: Sex Roles and Role Conflict in Nineteenth-Century America" (1972), reprinted in Disorderly Conduct: Visions of Gender in Victorian America (1985), p. 197.
[30] "Under the broad rubric of hysteria, nineteenth-century physicians gathered cases thast might today be diagnosed as neurasthenia, hypochondriasis, depression, conversion reaction, and ambulatory schizophrenia" - Smith-Rosenberg, p. 197.
[31] Smith-Rosenberg, p. 199.
[32] Ann Douglas Wood, "The Fashionable Diseases: Women's Complaints and their Treatment in Nineteenth-Century America," in Journal of Interdisciplinary History, No. 4 (1973), p. 26.
[33] Markell Morantz, p. 649.
[34] Josef Breuer and Sigmund Freud, "Case Histories: Fräulein Anna O.," in Studies in Hysteria (1895), pp. 21-2.
[35] Wood, p. 26.
[36] Elaine Showalter, The Female Malady: Women, Madness, and English Culture, 1830-1980 (1985), p. 3. - "Hysteria as a chronic, dramatic, and socially accepted sick role could thus provide some alleviation of conflict and tension, but the hysteric purchased her escape from the emotional and - frequently - from the sexual demands of her life only at the cost of pain, disability, and an intensification of woman's traditional passivity and dependence." - Smith-Rosenberg, p. 207.
[37] Maryann Bird, "System Overload. Excess information is clogging the pipes of commerce - and making people ill", in Time Magazine, December 9th, 1996, p. 46. Other symptoms mentioned in the article are stomach pains and deteriorating eyesight - obviously the "Information Fatigue" diagnosis is nearly as variable as beard's neurasthenia.
[38] Bird, pp. 46-7.