How Everyone Became Depressed (5 page)

The spas, especially those offering the hot springs and mineral-water-bythe-cup of hydrotherapy, unfurled their banners for nerves in anticipation of their later reception of neurasthenia (see below). Here, for example, is Ewald Hecker, who together with his teacher Karl Kahlbaum, coined the diagnosis hebephrenia in 1871, a precursor of schizophrenia.
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In 1882 he had just founded the Clinic for Nervous Illness at Geisenheim near Wiesbaden, in the Rhine valley, on the site of a former hydrotherapy station. What kind of nervous diseases did they treat? All kinds: peripheral nervous diseases such as paralyses; chronic brain and spinal diseases; general neuroses, such as “hysteria, chorea, hypochondria and spinal irritation; general nervosity, such as chronic headache, insomnia, general nerve irritation, psychic dysphoria, mood changes.” In addition, they also treated “Patients recovering from psychoses.”
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These are, for the most part, all real illnesses, but to group them tidily in the same facility and pour water on all the patients shows the firmness of the conviction that much illness was reducible to nerves. Within this vast panoply of nervous problems, however, the core was the nervous syndrome, and in treatment, Hecker over the years drifted ever more in the direction of psychotherapy.

The golden years of nerves were from about 1860 to World War I. In 1872 the little section for the electrical treatment of nervous diseases that James J. Putnam had just founded at the Massachusetts General Hospital served just over 70 patients. By 1903 this unit, now the Out-Patient Department for Diseases of the Nervous System and still under Putnam’s direction, had, as historian Eugene Taylor tells us, “moved into successively larger quarters three times … and in that year handled between 6,000 and 9,000 patient visits.” Most frequent of these “nervous conditions” were “epilepsy, chorea, neurasthenia, and hysteria.”
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Patients were no less full of talk about nerves than physicians. Young Russian Maria Bashkirtseff, a teenager living in Paris and aspiring to be a painter, was dying of tuberculosis; she wrote in her diary in 1874, “I want to live faster, faster, faster!” She knew that her time was growing short. Later in 1875 she wrote that “I am so nervous that every piece of music that is not a gallop makes me shed tears.… Such a condition of things would do honor to a woman of thirty. But to have such nerves at fifteen, to cry like a fool at every stupid, sentimental phrase I meet, is pitiable.”
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For this heart-rending young woman, nerves was more reduced to sadness, an affective disorder, yet she interpreted her mood as nervous in nature, not depressive.

By 1900 nervous disease had divided into two distinct populations: first, a nervous basin for those suffering every neurological and psychological ailment imaginable, a broad band of diseases that indicates that the term had no specificity at all; and second, the highly focused population of those with the nervous syndrome, or nervous package, that included depression, anxiety, fatigue, somatic symptoms, and obsessive thoughts.

This latter meaning of nervous syndrome was in its twilight toward 1900, although it was still powerful. In 1908 a “private select home,” meaning psychiatric unit, in Dundrum near Dublin offered “rapid and perfect cures” to “nervous ladies and voluntary boarders,” the latter meaning patients who voluntarily agreed to admission and could sign out again (almost) any time.
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Family physicians recognized at once the significance of a term such as “chronic nervous patients”: They might find your office after a long surgical history, as W. Gray Schauffler, with a 9-year practice in Lakewood, New Jersey, told the medical society of that state in 1906: “If a woman, she has already been the rounds of the gynecologists with varying degrees of relief and has realized that they can do nothing more for her; and if a man, the chances are that surgery has long since done its utmost by removing a doubtful appendix. And so the poor creature comes into our hands in a truly pitiable condition of suffering and despair.”
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There clearly was an army of the nervous out there, who together with their physicians had initially defined their problems as organic and correctible with surgery, only later to come to the end of the road.

Thus all orders of society knew nervous disease, from the small towns of New Jersey to the top of the London social heap. Alfred Schofield had a fashionable nervous practice in Harley Street in the west end of London, the street where elite medical specialists with brass plaques at their front gates tended to cluster. And Schofield was quite sympathetic to the many women and men—many more of the former than the latter—who came to see him for nervous irritability, neurasthenia, and the like. “The battlefield of life is increasingly on a psychic rather than a physical plane,” he wrote in 1906, at age 60 years. What if the patient had “nervous irritability,” the Griesinger diagnosis, rather than “nervous debility,” or fatigue (which will be treated in the next chapter)? In that case she cannot be “put to bed,” meaning given the rest cure. Send her away to a spa with “an experienced nurse-companion,” until her “nerves are stronger and quieter; and then may come travel or a restful voyage.”
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It is impossible to read these lines today without thinking that they must have been written on a planet other than the one we inhabit. But Schofield’s patients had the same illnesses that we do today.

Shortly, the nervous syndrome would disappear and be replaced by depression. Nervous disease as a long spectrum of quasiphysical illness would be replaced by psychological disease.

Let us try to unpack nervous disease. What does it consist of ? For one thing, most of the patients are tired, even exhausted, and one of the main components of the nervous picture is fatigue.

Today, psychiatrists do not think of fatigue as a terribly important symptom. After such obvious sources as iron deficiency have been eliminated— and it has been determined that the patient is not suffering from one of those quasidelusional disorders such as “chronic fatigue syndrome”—most clinicians would be inclined to ascribe fatigue to depression. For patients, however, fatigue remains a hugely important matter. A study of Stirling County in Canada’s Atlantic provinces in 1970 found that only 6% of psychiatrists considered fatigue to be serious; by contrast, people in the community reported “feeling weak all over” as one of the most serious symptoms among a list of 46.
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In hospital charts today it is not uncommon to see the acronym “TATT,” Tired All The Time.

The complaints of the fatigued and weary echo across the ages. In 1712 Lady Mary Wortley Montagu, en route in a journey, complained to a correspondent, “This is what writing tackle the Inn affords, and my head and hand are both disorder’d with fatigue, both of mind and body.” Lest psychological fatigue be thought mainly a women’s complaint, one of the “grand asthenics” of all time was Parisian novelist Marcel Proust, who, around the turn of the century, was so droopy with fatigue—his medical father had written a book on the subject!
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—that he barely made it from his bedchamber. His correspondence from 1909, for example, mentions fatigue throughout. On Friday, November 26, after his guests had departed, “I set about demolishing what I had written. And over my heart, fatigued from this absence of repose, voil à the fog that rolls in again. It’s about three in the afternoon and [another nervous] crisis seems to be starting up.”
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Whatever period or social class is under discussion, fatigue simply tumbles from the page. A keen young female scholar studying working-class housewives in a German industrial city just before World War I described a wearying struggle just to make ends meet: “A tired indifference speaks from the eyes of these women, who only seldom muster the strength to express a wish or a hope.” When asked where and how they might like to spend old age, they respond, “Where we get enough to eat our fill.”
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The fatigue of grinding poverty is well known, and had they been prosperous enough to see a doctor, which of course they weren’t, their fatigue would doubtlessly have been medicalized with a diagnosis such as “neurasthenia.” The point is that the grinding conditions of life can produce disorders that seem to pivot about exhaustion.

This fatigue of the miserable bears a superficial resemblance to the fatigue of bored, upper-middle-class London women in the 1920s. Archibald J. Cronin, a young Scottish doctor just trying to build a practice in London, discovered how many of his well-heeled female clients were “rich, idle, spoiled, and neurotic.” “I even invented a new disease for them—asthenia.” This magical word opened many a salon. His patients might say to each other, “Do you know, my dear, this young Scottish doctor—rather uncivilized, but amazingly clever—has discovered that I’m suffering from asthenia. Yes

… asthenia. And for months old Dr. Brown-Blodgett kept telling me it was nothing but nerves.” Cronin began giving his patients strengthening injections. “Again and yet again my sharp and shining needle sank into fashionable buttocks, bared upon the finest linen sheets.… Asthenia gave these bored and idle women an interest in life.”
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This is not the same fatigue, of course, that these worn-down German women endured—yet the denizens of these London salons believed themselves to be tired and not just suffering from “nerves.”

Thus fatigue occupied center stage in the nervous illnesses. George Waterman, a neurologist at the Massachusetts General Hospital, said in 1909, “Taking the various forms of the psycho-neuroses as a group there is no one symptom so frequently encountered as that of fatigue.”
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Asked about “fatigue, weariness and downheartedness,” a third of the women in a rural area of Sweden polled in 1947 responded yes (a much smaller percent of the men).
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Psychiatry has always tried to bind fatigue into larger concepts. In the past fatigue was central to the nervous package. As German psychiatrist and philosopher Karl Jaspers worked during World War II on the last edition of his great textbook of psychopathology that he would personally edit, he noted that “tiredness” was “one of the basic concepts of neurophysiology.” Any theory of how brain and mind worked, he said, would have to come to grips with tiredness and exhaustion (Ermü dung and Ersch ö pfung). Indeed, said Jaspers, the main theorists of the twentieth century, such as Pierre Janet and Sigmund Freud, had postulated “energetic” theories of mental phenomena: “Energetic theories regard the subconscious mind as a force that has quantitative properties. This force can ebb away, is subject to change, can pile up at obstacles and thereby increase in pressure; it can bind itself to particular objects, and transfer itself from one object to another.”
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Thus tiredness sits at the middle of the whole diagnostic basin of nerves.

Let us attempt first a brief history of fatigue before looking at the psychiatry of it. The exercise is somewhat academic because today, of course, fatigue has vanished from psychiatry.

The first point is separating the history of subjective sensations of fatigue and weariness from the history of medical interest in the subject. Before 1900, real levels of fatigue would be expected to be very high, for several reasons.

One is the exhaustingly long work day in farm and craft shop, where most people labored before the great expansion of urban life began around mid-nineteenth century. For most urban dwellers at the beginning of the twenty-first century, it is simply unimaginable how long and hard people used to work—and how exhausted they were from their labor. Just before World War I, a young German doctoral student named Maria Bidlingmaier, who died during the war, did a work–time study of women’s days in a rural community in Württemberg. This was an era when women were fully engaged in farm work in addition to running the household and raising the children. Bidlingmaier interviewed 77 married women obligated to work in the family fields: Their average work day lasted 14 hours, leaving home for the fields around 6 am and returning evenings around 8 or 8:30 pm. The women’s entire work day, household chores included, was 17–18 hours. Bidlingmaier commented: “In these numbers lies much secret grief for the peasant women, much courageous determination to get it done, much weary dragging home on dusty country roads, torrents of sweat in the heat of the summer, much staunch persistence in the work that is their duty, much resentment against the harshness of fate, and much exhaustion … ”
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The work of these Württemberg farm wives was unusually well documented. Yet their world was typical of an entire way of life that once prevailed in Europe and the United States when, in a premechanized era, work was done by hand, hour after endless hard hour, in the fields and the carpentry shops. This is now all vanished in the West, and our conception of hard work, though hard for us, has nothing in common with this former reality for millions of people.

Yet few of the physicians of the day saw “fatigue” as a medical complaint. In the older medical literature, there are almost no references to fatigue or any of its synonyms as medical complaints. At the end of the eighteenth century, a literary genre called the “medical topography” arose, in which local physicians described the hygienic and medical conditions of their district. There are hundreds of these. In almost none of them is fatigue ever mentioned, despite the local population having conditions of work as exhausting, or even more so, than those described by Bidlingmaier.
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Medical historian Peter Voswinckel notes the appearance of “fatigue” in German medical writing only toward the end of the nineteenth century.
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After the last third of the nineteenth century, these brutal working conditions started to come to an end. Objectively, we would expect real levels of fatigue in the population to decline. Time becomes available for recreation. Field and shop become mechanized with the advent of the electric motor. Work times in establishments become regulated. Unions demand the 10-hour day, then the 8-hour day. People begin to eat more protein and fat as they can afford to add meat to diets that previously consisted heavily of starchy porridge.
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Iron-deficiency anemia was once a major cause of women’s fatigue in particular, owing to chronic blood loss from the menses and repeated childbearing. Low iron in your hemoglobin means fatigue, and it is interesting that in Britain the percentage of women admitted to hospital with “chlorosis,” the old-fashioned term for iron-deficiency anemia, dropped from 23.2% in 1901– 1903 to 8.4% in 1913–1915, evidence of a meatier diet. (Hemoglobin rates rose correspondingly.)
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As well, postinfectious fatigue was once very common, meaning the exhaustion that patients experience after a severe infection. But with the urban hygiene movement of the nineteenth century, infectious illness began to decline. The last major pandemic western society experienced occurred in the years 1917–1923 with influenza, together with an associated epidemic of encephalitis lethargica (the two are not the same disease). And encephalitis lethargica, also called “Von Economo’s disease,” carried with it a crushing postinfectious feeling of fatigue, hence the term “lethargica.”
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As these terrible epidemics died away, the total fatigue burden of the population would have lessened.
Yet paradoxically, at the same time medical interest in fatigue quickened. Physicians who previously could not have cared a hoot about their patients’ tiredness now came alive to it. Scottish psychiatrist James Crichton-Browne, who in his 80s produced several charming volumes of puckish medical observations, gently mocked his colleagues in 1926 for their fatigue alarmism: “Fatigue, over-fatigue, is one of the great dangers of our day, and the ease with which it is [medically] induced is perhaps one of the signs of our degeneracy.” He contrasted a tough-minded Scottish dowager, “vigorous and sarcastic at the age of ninety-six,” portrayed in a contemporary novel, with her greatgrandniece, Miss Douglas, who constantly was running off to the South “on account of her health.” It was not the dowager who was fatigued.
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Still, there is a serious point here. The medical discovery of fatigue, as Anson Rabinbach notes, marks “the association of fatigue with pain,” in contrast to the older perception “of fatigue as the necessary accompaniment of work.”
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Rabinbach might have extended the point to include not just pain, but depression, anxiety, and somatic symptoms other than fatigue as well, plus a kind of obsessive fretfulness in general—that were all the companions of nerves.

Several new phenomena in the patients’ world might have elicited this new interest among physicians. Exactly what happened here is still quite obscure, and key events antedate the popularizing of the term “neurasthenia” in 1869, so it is not simply that a medical term for fatigue arose and the patients obligingly followed by reporting tiredness.

One development is situated not in the world of peasants and laborers but among the upper middle classes, quite particularly among society women. It concerns women wealthy enough to have servants who “take to their beds,” and stay there for months, years, and decades. Medically, they were known as the “bed cases,” or the “sofa cases,” les femmes à chaise longue, and they w ere common among the upper-middle-classes of the big cities. What exactly was wrong with these women was never really clear, but they did complain of fatigue despite endless bed rest.

It was around the age of 37, in 1839, that Harriet Martineau, later to become a popular English author, took to her bed. Offspring of a well-off English provincial family, she had been sickly as a child and complained often of fatigue, but finally as an adult she had become “exhausted” by it and sought the sick room. Her self-pitying account “Life in the Sick Room,” published anonymously by “An Invalid” in 1844, struck a nerve and became widely read. In addition to “long hours of weary pain,” she suffered from “besetting thoughts,” insomnia, and, as she put it, “nature’s feebleness and apparent decay.”
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Looking back on these years in her autobiography, she mentions “a depressing malady.”
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Harriet Martineau’s autobiography, written in 1855 but not published until 1877, emphasizes fatigue more strongly. “ … Considerate persons will at once see what large allowance must in fairness be made for faults of temper, irritability or weakness of nerves … in sufferers so worn with toil of body and mind as I, for one, have been. I have sustained, from this cause [her deafness], fatigue which might spread over double my length of life.” This is not to belittle the sufferings of the deaf, of course, but to show that she experienced them as fatigue. Soon, her writing had put her in a state of “nervous exhaustion.” She numbered herself among the “brain-worn workers” and was at pains “to save my nerves from being overwhelmed.” By her early 30s she was, she reveals, “exhausted with fatigue,” her nerves “overstrained.” After the end of her “sick room” reclusion, around 1845, she continued to suffer subjective debility while maintaining an active and successful literary career. At age 52 she apprehended the approach of death (in fact she lived another 20 years) and experienced “a creaking sensation at the heart” and “sinking fits.” The litany of woe and fatigue then comes to an end because, believing that death was nigh, she hastily concluded her autobiography.
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Harriet Martineau was singular in her literary talent but typical of an entire social class of invalids and shut-ins whose nerves were exhausted and were now taking to their sofas and beds. In 1881 Silas Weir Mitchell, a leading scientific figure in neurology who also had an upscale private practice in Philadelphia, referred to “hysterical motor ataxia,” the inability or unwillingness to walk based on psychological grounds. The disease, he said, “adds many recruits to that large class which some one has called ‘bed cases,’ and which are above all things distinguished by their desire to remain at rest.”
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