F. G. Gosling, Before Freud: Neurasthenia and the American Medical Community, 1870-1910 (Urbana: University of Illinois Press, 1987).
Gosling provides a history of neurasthenia before Freud entered the scene of American psychology that considers those outside the “elite” group of physicians (Beard, Mitchell, and co.) who developed the concept in the late 19th century. As a mental illness constructed by physicians and their patients, Gosling argues neurasthenia provides an excellent inroad into the “gender and class biases” that the disease served to justify.
Chapter 1: The Price of Progress
Starts with George M. Beard (how could you not), New York neurologist who came up with a new disease called “neurasthenia,” or “nervous exhaustion,” which lent legitimacy and respectability via a disease etiology to a class of people not insane (many continued to function in their jobs) but victim to an exhaustive collection vague of symptoms like “headache, fatigue, dyspepsia, [and] depression…” (9)
In Beard and his colleague’s estimation, the disease was uniquely American problem attributable to a people evolving slower than their technologies; “Arguing that cultural evolution had outstripped the pace of individual evolution, he maintained that specific features of the young American society — in particular the telegraph, the railroads, the periodical press, the sciences, and the atmosphere of political and religious liberty — had increased mental demands on Americans, especially on the urban professionals who labored with their heads rather than their hands.” (11)
Timeline — Written about by Beard in 1869, reached peak popularity in early 1900s and was fading in relevance after 1910. (13)
Goes into the history of neurology, which was (of course) modeled in America after Continental examples. First organization was the American Neurological Assocation, based on the east coast (35 people met in 1875 to form it, most of whom were from big eastern cities; “a few” lived in Chicago and St. Louis). Argues that “neurologists” were “curious blend[s] of physician, psychiatrist, and anatomist,” more like modern-day psychiatrists than neurologists “because of their emphasis on the emotions and the social origins of stress.” (16-17)
Lack of specialization in rural communities meant that GPs were treating neurasthenics. (25)
Chapter 2: Nerve Invalids All
Discusses physicians’ (not just the main ANA people) understanding of neurasthenia; when they diagnosed it, what symptoms were indicative of it.
“Many physicians believed that early intervention in cases of neurosurgery degeneration could often restore patients and prevent development of true psychosis. Though patients with pronounced mental symptoms could be trying, they could often be saved from asylums if physicians recognize the dangerous grounds on which they stood and implemented an early treatment program that incorporated mental as well as physical remedies.” (45)
Discusses sexual habits, work habits, etc., highlighting the way that genders and classes were asked different questions about their habits and had a different threshold for “overwork”; i.e., women who were engaged in activities that weren’t as culturally acceptable (going to college), this could be seen as an overexertion leading to the neurasthenic state. Men were asked more about their masturbation habits (and had diagnoses based upon them) because it wasn’t as sensitive of a subject with male patients and male doctors (it would be indelicate to ask a woman).
Treatment, based as it was on causes constructed from the patient’s class and gender, was often effectual, even if it seems extreme or stupid from a modern perspective; “Most of these patients were, in fact, ‘nervous’; they were not unwilling guinea pigs but sufferers who sought relief. If doctor and patient shared faith in a particular remedy — be it surgery, drugs, or applications of electricity — the patient was often truly benefited, though relief may have been temporary.” (62)
Understood as very idiosyncratic, based on a “thorough examination of the patient with complete family history, appropriate medicinals, and various psychological measures…” They were not often thought to work overnight, but required “tact, patience, judgement, and true sympathy” from doctor to patient. They often required close supervision from the doctor over a lengthy period of time. (67)
Chapter Three: On the Verge of Bankruptcy
Journal literature was extremely widespread; beginning with Beard’s enumeration of the disease, publications began appearing in the 1870s, had become a “flood” by the mid-’80s, and “reached a peak between 1900 and 1910.” (78)
Overwhelming variety of symptoms were placed into categories by Beard’s colleagues and successors, one of which was “digestive.” Seems to have included constipation and dyspepsia. (80) It was understood, however, that oftentimes the physical symptoms were the result of underlying mental distress. (83)
Usually diagnosed among the middle- and upper-classes because the neurologists developing the disease etiology treated mostly wealthy patients and because physicians often made distinctions between patients of different classes (their clinical vs. private practices). Working-class diagnoses were often attributed to muscular overwork, which could manifest in a form of the disease called “spinal congestion” (83-84)
Believed to be hereditary, leading to ideas of “constitutional nerve capacity,” and physicians encouraging patients to “live within their means of nervous energy.” (85-88)
Tried to acquire and air of scientific legitimacy via the “waste versus despair” theory and the diathesis concept — playing into electro-physics and physiology. Didn’t do much real research though. (88-89)
Modern transportation as pathological —
Survivors of railway and steamship accidents could have a sort of 19th century techno-induced PTSD – “Railway spine” (91-92)
Discussion of “overwork” in the context of middle-class white collar workers (92-95)
“Neurasthenia attributed to overwork occurred most often in men of the ‘better sort’ whose natural ambition and competitive environment drove them to the breakneck pace and assumption of too many responsibilities that all too often led to nervous exhaustion.”
Women’s neurasthenia more often attributed to the biological, resulting from “the upsetting of their more delicate nervous equilibrium.” Believed to be more numerous and more likely to be neurasthenic.
Gosling argues that literature from medical journals indicate a widespread and relatively consistent idea of what neurasthenia was — they use similar terms, even when they’re debating about the specifics. “…this knowledge was as available to country doctors and general practitioners as to urban neurologists; there were no significant differences between ANA members, independent neurologists, and non-neurologists in their perceptions of neurasthenia.” (105)
Chapter 4: Not the Physic but the Physician
Much less agreement as far as treatment went; usually aimed at treating symptoms, falling into major categories — “rest, regulation of the diet, exercise either active or — in a form such as hydrotherapy — ‘passive,’ and drugs to aid digestion, enervate the nervous system, or induce sleep…” Often employed several methods. (108-109)
More doctors recommended travel as the century wore on (second most popular treatment option after rest in 1900) (108)
Sometimes suggested exercise, which would improve appetite, digestion, increase muscle tone, and distract the sufferer from his/her problems. (120) Passive exercise was recommended for patients too weak or in pain for physical activity; hydrotherapy was a popular option and included the use of methods as wide ranging as “enemas to sponge baths…[and] hot and cold packs to the spine.” (122)
“Exercise ‘dissociated from one’s vocation,’ changes of scenery, and new associations” were believed to break “habitual patterns of behavior,” providing a refreshing change. These changes helped establish healthier lifestyles and modes of thinking. Less based in physiology/hard science, this kind of ‘mental therapy’ grew in popularity toward the end of the 19th century. (132)
One “excellent example” of this trend is climatotherapy; physicians and specialists began prescribing travel “to a more healthful environment to replenish… nerve stock.” Concedes that there was some debate about what kinds of environments/climates were especially salubrious, but mountains were definitely up there. (133)