How Everyone Became Depressed (6 page)
The second half of the century saw the foundation of many high-end private nervous clinics and sanatoriums, catering to the fatigue crowd (on the owners’ fondness for neurasthenia as a diagnosis, see below). It was a whole art, judging where to send patients who suffered from “general weakness,” and in 1882 a German spa guide cautioned, above all, not to refer them to places with a high-altitude “strengthening” climate. Much more advisable were watering places in the front ranges and in valleys, “depending on the degree of weakness and especially on the amount of energy that is present in the nervous system.”
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Thus was the spa world crafted for the weary. The Sanatorium Val-Mont in Montreux-Territet, a pricey Swiss spa-resort, featured in 1908 as an indication for admission “fatigue resulting from overwork.”
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Perfect. Whom should we find there in 1913 but Marcel Proust.
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Fatigue thus slumbered on, in a sense, for decades and centuries as plain old weariness, or as part of a larger nervous picture, until it suddenly became a disease of its own. This is usually bad news for patients, when a symptom turns into a disease. Maurice Craig, a psychiatrist at Guy’s Hospital in London, deplored in 1917 “the mistake of naming a disease according to its most prominent symptom.” He was talking about “depression,” because low mood is found in many different disorders.
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But the stricture applies to fatigue as well. This kind of medicalization fixes attention on a given symptom so that it becomes the elephant in the room rather than just a found-in. Today, this has happened with vague bodily pains as they turn into “fibromyalgia,” ensuring that the bearers of the fearful diagnosis will become disabled.
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In the past this happened with fatigue in the form of “neurasthenia.” Boston neurologist James J. Putnam, who established the first nerve clinic in the United States at the Massachusetts General Hospital, said in 1899, “To feel ‘tired’ may be bad enough at the best, but it makes a world of difference whether one accustoms himself to take the term as meaning the fatigue of a person who expects in due time to be rested, or as a bottomless pit of exhaustion, demanding sighs and groans.”
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It was this that “neurasthenia” accomplished.
Wh at fixed the attention of everybody—doctor and patient alike—upon the phenomenon of tiredness, to the exclusion of everything else in the nerves package, was the coining of the diagnosis “neurasthenia” by New York electrotherapist George M. Beard in 1869. To be sure, the term neurasthenia had been used before and Beard did not literally coin it. But his 1869 article in a prominent American medical journal, and following book in 1880, gave the diagnosis a kind of viral spread.
Beard’s neurasthenia bombshell burst into the medical world with an article in 1869 in The Boston Medical and Surgical Journal, which was the forerunner of the New England Journal of Medicine. In a talk in 1868 to the New York Medical Journal Association, Beard said, “I am to speak to-night of a condition of the system that is, perhaps, more frequently than any other, in our time at least, the cause and effect of disease. I refer to neurasthenia, or exhaustion of the nervous system.” Thus at the beginning, Beard appeared to be referring not to a whole syndrome but to the specific symptom of tiredness, the result of the central nervous system becoming “dephosphorized … and as a consequence becomes more or less impoverished in the quantity of its nervous force.” But attentive listeners on that evening would have learned that Beard was in fact speaking more of a nervous syndrome than an isolated symptom: “If a patient complains of general malaise, debility of all the functions, poor appetite, abiding weakness in the back and spine, fugitive neuralgic pains, hysteria, insomnia, hypochondriasis, disinclination for consecutive mental labor, severe and weakening attacks of sick headache, and other analogous symptoms … we have reason to suspect that … we are dealing with a typical case of neurasthenia.”
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So, from the outset, neurasthenia was really just a synonym for nerves, but one that focused in particular upon the component of fatigue.
Beard’s 1880 book, A Practical Treatise of Nervous Exhaustion (Neurasthenia), reached a wide medical audience and was at once translated into the most important medical language of the day: German. Indeed, it was dedicated to the Heidelberg neurologist Wilhelm (“William”) Erb, one of the major international authorities, with whom Beard was by now bosom buddies. Here Beard made it clear that he included in neurasthenia a variety of anxiety disorders, including phobias and obsessive-compulsive traits (one of his patients was unable to “go more than half a mile in a straight line”); others displayed what would later be hived off as “social anxiety disorder”: “This aversion of the eyes is so constant a symptom in neurasthenic patients that I often make the diagnosis as soon as they enter the office, before a word has been spoken by either party, and even before the patient has had time to be seated.”
And insomnia! “One man finds no difficulty in getting to sleep on retiring, but soon wakes, and must remain awake for the rest of the night.” Beard’s patients had disorderly intestinal tracts. “Flatulence with annoying rumbling in the bowels these patients complain of very frequently; also nausea and diarrhoea.”
Some of the symptoms of neurasthenia were almost certainly the result of medical suggestion, such as “crawling, creeping, and burning sensations” along the spine, a holdover from the days of “spinal irritation” (which Beard considered part of neurasthenia).
Beard believed “nervous exhaustion” to be synonymous with neurasthenia, and in the 1880 book he dilated upon, “This feeling of exhaustion, though not exactly pain in the usual sense of the word, is yet, in many cases, far worse than pain.” Exhaustion might come on in what would later be called “panic attacks”: a kind of “going-to-die feeling,” Beard said. Beard avoided describing symptoms of depressed mood, probably because he did not want to risk having his precious diagnosis conflated with melancholia or even with what people were already referring to as “depression.” Yet he could not avoid the subject. On variations in muscular strength, he said, “One may have great mental depression at times, or at all times may have neurasthenic asthenopia, the various forms of morbid fear, general debility in its various phases, and yet be capable of great muscular endurance.” One of his patients, a physician, “gave a perfect history of the disease [neurasthenia]; but when I asked him if he was subject to mental depression, he replied: ‘I passed through all that;’ and this I observe oftentimes of neurasthenics in middle life, that symptoms of the early stages of the disease, such as mental depression and dyspepsia, have ceased their annoyances.”
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So mild depression was definitely part of the picture.
The many advocates of neurasthenia in the decades ahead increasingly avoided the expression “nerves,” which now seemed too old-fashioned, and shunned as well phrases conveying mood disorders, because they wished to cling to the organicity of neurasthenia, rather than turfing their booty to the psychiatrist.
But booty there was aplenty. Medical empires became founded on neurasthenia. Physicians set up profitable consulting practices as neurasthenia specialists, not psychiatrists to be sure, but not your ordinary run-of-the-mill doctor either. Paul Hartenberg in Paris saw mainly patients with hysteria and neurasthenia and profiled his high-end practice along those lines. Yet, trained by internist and hypnotherapist Hippolyte Bernheim at Nancy, he was not a psychiatrist. He was 41 years old when in 1912 he published his widely read Treatise on Neurasthenia, featuring patients such as “the forty-ish man who entered my office and said to me, ‘Docteur, I’ve come to consult you because I am always fatigued and incapable of working. When I get up in the morning, I am tireder than the night before. During the whole day, I feel my body, my limbs all stiff. The slightest effort exhausts me, and I can no longer go for walks or take any physical exercise. Even standing upright is painful.’”
Thus far, a clear-cut fatigue case, right? But there is more. “But I’m tired, not just in the body but in the head. There is constantly a tension band about my scull. I feel that my head is empty. My mind refuses to work. My thoughts are confused and I can no longer fix my attention. My memory is shot. When I read, I no longer know by the bottom of the page what I’ve read at the top. I forget my appointments, my business affairs.” This certainly sounds like depression.
And it is: “With all that, I’m sad. I am bored to death everywhere and always. Everything that other people find amusing leaves me flat. I take no pleasure at anything.” These are classic symptoms of depression. But Hartenberg’s patient was also anxious: “I am worried about everything. The slightest problem alarms me. The least upset exasperates me.” Moreover, this forty-ish man had “lost his appetite, slept poorly and had no sexual desire.”
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Doctor, your diagnosis? Today we would say unhesitatingly “major depression,” with comorbid anxiety. But there is nothing that differentiates Hartenberg’s patient from the many other nervous patients of history, merely that the both the patient and Hartenberg chose to focus on the man’s fatigue, rather than on his anxiety or dysphoric mood. Fatigue is not a medical emergency. The complete absence of pleasure in life is, because these patients are inclined to suicide.
Every big city had its Doctor Hartenberg, the neurasthenia specialists who sometimes were genuine scientific figures as well, such as Hermann Oppenheim in Berlin, or sometimes they were just medical businessmen. Oppenheim, a leading neurologist of the day, also received nervous patients from all over the world in his private clinic. He wrote in his Textbook of Nerve Diseases, a leading neurology textbook, “Neurasthenia has become a widespread illness in our society. One encounters it with special frequency among the residents of the big cities. Even though it might have been present in all epochs, and has long been familiar under the term nervousness, nonetheless in recent decades it has doubtlessly increased phenomenally, with the constantly growing haste and unrest of existence, with the extreme increase in challenges that life, work, livelihood, and pleasure-seeking that all demand.”
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What gave impetus to the business side of neurasthenia was the discovery in 1875 of a “cure” for it: Weir Mitchell’s rest cure. Rest cures had a long history in medicine, putting patients to bed in the hopes that they would more or less recover. But in a world awash with neurasthenia, Mitchell’s particular rest cure was a brilliant innovation as it involved isolating the patient in a private room, subject completely to the authority of an authoritarian physician (and enforced by Amazonian nurses); a milk diet to fatten up these emaciated women—and they were almost all women—many of whom had been eating poorly; small peripheral doses of electricity to get those exhausted muscles contracting again; and vigorous massage: some claim that by introducing massage into medicine, Mitchell was the founder of physiotherapy.
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Because the rest cure demanded private rooms, special nurses, electrical apparatus, and other equipment, it could be most easily performed on in-patients, and the number of physicians willing to raise the capital for exclusive private clinics catering to wealthy female neurasthenics was very large. Of course these private clinics treated nervous and mental diseases other than neurasthenia, but it was a flagship diagnosis, and in their advertising to the medical profession, the owners featured it prominently, along with the availability of the “milk diet,” as the Mitchell cure was often called in Europe, among other physical and dietetic treatments.
The private clinics that conducted rest cures were legion, but to give a concrete sense let’s look at Anton Frey’s “Sanatorium Frey-Gilbert” in Baden-Baden, Germany, an exclusive watering-place noted for its casino— one that exists even today, along with the famous Brenner’s Park Hotel—and for Baden-Baden’s numerous private clinics located near the warm springs. (It was to these springs that the town owed its rise to fame, in contrast to the cold springs that previously had ridden the hydrotherapy crest elsewhere; Baden-Baden physicians claimed to treat nervous disease in particular.) At the Frey-Gilbert sanatorium, nervous diseases were the first order of clinical indications for admission, and included “neuralgia, neurasthenia, hysteria, hypochondria, and insomnia.” Therapeutically, the clinic specialized in dietary cures, especially the “milk cure—Mitchell, Playfair.”
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(Named after William S. Playfair, the London gynecologist who introduced the Mitchell rest cure to England in 1881.)
In the United States, neurasthenic patients had an array of choices, including Weir Mitchell’s own private clinic in Philadelphia. Yet there were private nervous clinics in many places; in Des Moines, Iowa, neurasthenics were received at “The Retreat: A Private Hospital for Nervous and Mental Cases.” Led by Gershom Hill, then 67 years old and a graduate in 1886 of Rush Medical College in Chicago, the Retreat billed itself as “a large, quiet home, for neurasthenic and mild mental cases.” Its treatments included “rest.”
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The “Oconomowoc Health Resort for Nervous and Mental Diseases” in a town by the same name in Wisconsin, “three hours from Chicago” by rail, possessed an imposing building, newly built in 1913, and equipped “to supply the demand of the neurasthenic, borderline [psychotic] and undisturbed mental cases.”
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These private clinics were substantial affairs, and neurasthenia was a diagnosis one could take to the bank.
In these private sanatoriums for “nervous and mental disease,” neurasthenia was definitely a nervous condition, not a form of madness. It was psychiatrists who treated “mental disease,” meaning patients who were psychotic, melancholic, or demented. Psychiatry entailed insanity; nervous disease represented a physical condition of the nerves of the body, those exhausted nerve centers, as Beard put it, that just needed some phosphorus.
As neurasthenia sat on the cusp between internal medicine and psychiatry, who should march into the office of one of the London west end’s neurasthenia specialists, Frederick Parkes Weber on fashionable Harley Street, on June 29, 1907, but the Reverend X, age 50. Parkes Weber was the son of Sir Hermann Weber, who had emigrated earlier from Germany to England and specialized in spa referrals. Frederick was similarly a spa consultant, and his wealthy patients often spent the summer season traipsing from one continental hot spring to another. For the Reverend’s “neurasthenic condition (irritable weakness)” Parkes Weber thought it right to send him initially to the English watering-places Buxton and Harrowgate.
