Wednesday, May 15, 2013

The poor to the madhouse, the rich to the spa: Neurasthenia in the 19th Century

The history of mental illness and psychiatry is a fascinating field that is always generating interest.  One would only need to glance at the program for the recent University of Calgary Conference "History of Medicine Days", to find new research on asylums, psychiatric pharmacology, or combat stress.  On this last topic, Terry Copp and Mark Humprhries' 2010 work Combat Stress In the 20th Century: The Commonwealth Perspective, compiles an impressive collection of primary sources from the archives and medical journals which outline the development of an understanding of mental breakdown on the battlefield.  Their introduction to the first chapter, "From Railway Spine to Traumatic Psychosis: Doctors Confront Trauma in the Modern Age, 1865-1918", shows how class and gender affected early thought on mental illness.

In the nineteenth century, public asylums could resemble medieval dungeons more than places of recuperation and rest.  Those committed to them were largely the impoverished, homeless cases deemed unstable and disruptive.  More affluent families with any compassion for a relation would certainly attempt to avoid incarcerating them here.  Instead of diagnosing these patients as insane, doctors would allow them to be classified as having "nerves".  As Copp and Humprhies write, "nerves allowed those with enough money to pay for treatment and a respectable diagnosis to wrap many of the more common mental illnesses in a linguistic cloak thus avoiding the stigmitization of the asylum". (p. 4)
Opening in 1247, London's St Bethlehem Hospital or "Bedlam"
 as it was known was the first dedicated strictly  to those with mental disorders.

Insanity was considered to be inherited, yet nervous disorders were thought to be acquired, and thus these were socially acceptable conditions.  Insanity reflected poor blood, while a nervous disorder may have just been reflective of being in the wrong place at the wrong time.  Psychiatrists, alienists, and neurologists were happy to be able to escape the practices of the asylum, and so by classifying the nervous disorders into neurasthenia, hysteria and traumatic neuroses, they looked forward to private practice with more well-heeled patients.
“Mistress and her maid,” by Jean Louis Forain.
University of Virginia Art Museum.
 http://www.hsl.virginia.edu/historical/reflections/fall2008/rest.html

Neurasthenia was thought to be a loss of nerve substances from the body.  Modernity, with its  railroads, electrification, and mechanization was thought to increase this dissipation of "nerve force".  While veterans of the American civil war were first to diagnosed, medical culture soon began to associate it with those who were on the cutting edge of the latest technologies.  Copp and Humpries record, "...a diagnosis of neurasthenia was often quite fashionable because it indicated that one was engaged with the modern world.  It grew in popularity so quickly that soon the link between veterans and the diagnosis was all but forgotten."  (p. 5)
Charcot demonstrates a case of 'hysteria' c. 1885 
http://www.richardwebster.net/freudandcharcot.html
 

Hysteria was a condition that was hard to distinguish from neurasthenia, and carried negative connotations with its diagnosis.  By the late nineteenth century it had become associated with undue sensitivity, moral weakness, and impulsiveness.  "Although it was similiar clinically to neurasthenia, hysteria resulted from the patient overexciting their own nerves through some specific idea or act.  Masturbation, obsession with romantic relationships, grief, and worry were all thought to unnecessarily tax the nervous system and sap the energies of the patient and, in extreme cases, produce a shock which resulted in the more pronounced hysterical symptoms like paralysis, blindness, and mutism." (p. 5)  With this contrast, it is clear which diagnosis was preferable for the patient!

The authors' note that it was the patient's class and sex that differentiated the two conditions to most doctors.  Patients from the upper class, of course, had "superior moral constitutions" and were less likely to succumb to the temptations which would bring on hysteria.  Women, however, thought to have less willpower and tendencies towards emotional outbursts, were also thought to be at risk.  It appears that wealthy women could turn a doctor's diagnosis in the favourable direction, as "...women of means were often able to find a doctor willing to label them neurasthenic." (p. 6)

Copp and Humprhies emphasize that after the Civil War, nervous disorders were increasingly accepted as a "more benign form of mental illness." They note that it was the pace of modernity that many blamed on the acute manifestation of these disorders:
At the heart of the diagnosis of neurasthenia was the notion that modernity itself was traumatic.  The mechanized, industrial slaughter of the Civil War and the hurdling pace of modern life were symptomatic of the trials and triumphs of the modern age and it was to be expected that man's feeble body would recoil in horror as it was further disconnected from an agrarian, rural past.  In the decades after the Civil War, doctors on both sides of the Atlantic were increasingly faced with victims who suffered from the after-effects of these head-on collisions with modernity. (p. 6)

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