Department of Psychiatry, St Bartholomew's and the Royal London School of Medicine and Dentistry, Basic Medical Sciences Building, Queen Mary and Westfield College, Mile End Road, London El 4NS, UK
Declaration of interest R.E.T. was funded by a Wellcome Clinical Epidemiology Fellowship.
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ABSTRACT |
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Aims To use empirical historical hospital data from one specific hospital to explore several controversies about neurasthenia, including what happened to the disorder.
Method The annual reports of Queen Square Hospital were examined from 1870 to 1947. The prevalence of neurasthenia diagnoses as a proportion of total discharges was recorded. The possible diagnostic categories into which neurasthenia could have been reclassified were identified. Textbooks and writing by neurologists working at the hospital during this period were examined.
Results Neurasthenia accounted for 6-11% of total discharges from the late 1890s to 1930, when it virtually disappeared. Men accounted for 33-50% of cases.
Conclusions Neurasthenia affected both the upper and working classes and both men and women. Neurologists, not psychiatrists, continued to see the disorder well into the 20th century. Neurasthenia did not disappear, but was reclassified into psychological diagnoses.
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INTRODUCTION |
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Myths outlined
Social-class bias
Beard propagated his view that the illness was due to a deficiency in
nervous energy, often found in businessmen or others exposed to the
competition, luxuries and vices of modern society
(Beard, 1972). He also felt it
was more common among those with a more refined nervous system, including
intellectuals and professionals. Indeed, he himself had suffered from the
disorder, as had other physicians such as Dowse and Mitchell, who were closely
connected with the condition (Jewell,
1881; Blocq, 1894).
Wessely (1996), in his history
of neurasthenia, writes that although initially a fashionable disease of the
upper classes, it spread downward through the social classes. He quotes a
series of papers from 1903 to 1911 which show that it was common in Jewish
immigrants, the garment workers of New York and the working-class patients of
the Vanderbilt clinic in New York. There is an implication here that the
disease spread to the lower classes. However, it may always have been
prevalent across all social groups, but was not observed in the lower classes
by the leading lights of neurasthenia such as Beard and Mitchell, whose
patients were exclusively drawn from higher social groups.
Neurasthenia was a female malady
The work of Elaine Showalter presents a feminist thesis on neurasthenia.
She paints a picture of neurasthenia in which its female victims languished
fatigued, often incapable of walking, on the chaise-longues of London and New
York, and included such well-known literary figures as Virginia Woolf,
Charlotte Perkins Gilman and Alice James. Although she does mention the
occurrence of the illness in middle-class men the main thrust of her argument
is that it arose in women as a form of protest against their empty and
unfulfilled lives (Showalter,
1985). Primary sources reveal contradictory views on the gender
distribution of neurasthenia. Some writers obviously saw it as a disease of
professional and intellectual men, for example, "it is a disease of
bright intellects, its victims are leaders and masters of men, each one a
captain of industry" (Pritchard,
1905). Dowse comments that in his experience it is common among
clergymen prone to overwork (Dowse,
1892). However, there was also a view that women were more
vulnerable owing to their weaker nervous systems. Allbutt & Rollesten, in
their weighty multi-volume medical textbook, wrote in the chapter on
neurasthenia "Young women are much more prone than young men to break
down in this way". They also voiced the common concern that the
increasing tendency to educate women could be leading to problems: "Many
women never get over a long and ambitious course of study... Many a brilliant
student or vigorous athlete has been thus wrecked, perhaps for life
especially among women" (Allbutt
& Rolleston, 1905-1911).
Disappearance of neurasthenia
Like hysteria, there has been an apparent diminution of the prevalence of
neurasthenia to the point where it actually disappeared
(Wessely, 1990;
Micale, 1995). Some writers
have assumed the reality of this diminution and have attempted to explain it
in various ways. Feminists have pointed to the emancipation of women and
liberation of sexual attitudes as important in decreasing women's need to
express themselves somatically (Showalter,
1985; Smith-Rosenberg,
1985). Within the medical profession the development of ideas
about the unconscious and the increase in psychological treatments are
postulated as a reason for the disappearance of disorders that were a physical
expression of distress (Swartz et
al, 1986). Shorter
(1992) explains the decreased
prevalence of neurasthenia as being due to a paradigm shift in medicine in
which neurasthenic symptoms came to be regarded as caused in the mind.
Somatising patients therefore selected other symptoms from the symptom pool,
seeking refuge in other diagnoses with a more organic flavour. However, it is
possible that neurasthenia as a symptom complex never actually disappeared,
but was simply relabelled as medical nosology evolved. This argument is made
by Micale, who emphasises diagnostic drift in the evolution of
disease categories (Micale,
1995). The same point is made by Wessely, who provides evidence
from primary sources that symptoms of neurasthenia were replaced by
psychological symptoms (Wessely,
1996). He also suggests a continuity between neurasthenic states
and the modern and equally fashionable diagnosis of chronic fatigue syndrome
or myalgic encephalitis (ME) (Wessely,
1990).
Abandonment of neurasthenia by neurology
The development of theories about psychogenic mechanisms began to take its
toll on the notion of neurasthenia as a functional physical illness. Shorter
describes how other psychiatric diagnoses gradually stripped away parts of the
neurasthenia syndrome. For example, in 1895 Freud removed anxiety neurosis
from neurasthenia (Freud,
1895) and in 1903 Janet introduced the term psychoasthenia, whose
core was obsessivecompulsive states
(Shorter, 1992). Meanwhile,
neurologists were moving in an organic direction, being increasingly
preoccupied with the huge strides they were making in terms of functional
localisation of the workings of the nervous system
(Bynum, 1985). Unfortunately,
neurasthenia remained stubbornly a functional disorder for which
they had been unable to find any structural pathology
(Gowers, 1893). Bynum
(1985) argues that by the First
World War most leading neurologists in Britain had left the treatment of
functional disorders to their psychiatric colleagues. Writing about the
British experience Wessely declares that "Neurasthenia was never
accepted by the Medical Establishment", "the giants of the
profession (neurology), such as Gowers, Gordon Holmes, Ferrier, Buzzard and
Kinnier-Wilson based at the National Hospital for Nervous Diseases, declared
themselves in various ways against an organic view of neurasthenia"
(Wessely, 1996). He poses the
interesting question of whether their academic disdain
translated into their clinical practice. This question can be answered
directly by the data produced by the current study, and it will also be
possible to examine the extent to which neurologists continued to treat
neurasthenia after the turn of the century.
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METHOD |
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Primary sources available at Queen Square
Three main primary sources are available at the hospital. First, there are
the annual reports of the hospital, which cover the period from the creation
of the hospital in 1860 to 1947. For most years the annual reports contain a
medical registrar's report, which presents statistical returns of the number
of discharges broken down by diagnosis, gender and outcome. Second, the
hospital archive keeps the clinical casebooks (1853-1947), each bound
according to the year, the consulting physician and the gender of the patient.
Third, the library holds a historical collection consisting of 3000 books and
monographs, all catalogued and this catalogue is available on the hospital
website. Although some are older the majority of these are 19th century. There
are also discrete collections of publications by staff who worked at Queen
Square during their careers, which were kept up until 1980. The historical
collection has grown with the hospital, and reflects the kind of textbooks,
pamphlets and monographs that would have been available to physicians working
at the hospital in the 19th century.
Use of primary sources
The bulk of this study focused on detailed reading of the annual reports.
All changes in the classificatory system of functional disorders
were recorded. A paradox database was used to record for each year the number
of neurasthenia diagnoses and the numbers of all other functional diagnoses,
by gender. In order to have a denominator total discharges were recorded for
each year. To enable comparison with a usually unambiguous organic diagnosis I
recorded the number of brain tumour diagnoses for each year by gender.
The clinical case records were not studied in detail but were examined primarily to answer the following specific questions.
Finally, I looked at the writings of the main consulting physicians over this period: Dr J. Hughlings Jackson (1835-1911), Sir J. Russell Reynolds (1828-1896), Dr Thomas Buzzard (1831-1919), Dr H. C. Bastian (1837-1915), Sir William Gowers (1845-1915), Sir David Ferrier (1843-1928), Dr C. E. Beevor (1854-1908) and Dr Kinnier Wilson (1878-1937). This will not be reported on in detail here, but my main aim was to ascertain their level of academic interest in the diagnosis. I also looked at which texts on neurasthenia were available in the library just before and after the turn of the 20th century, to ascertain what the physicians and their students might have been reading about the disorder.
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RESULTS |
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We are reminded of the complete separation of these functional disorders from insanity by the rules of the hospital, which specifically exclude "... persons of unsound mind". The reports also include references to aetiology, which are interesting in that they were written by physicians for the general public. There is a resonance with modern ideas about the aetiology of chronic fatigue, for example, in the report of 1894:
"The recent epidemics of influenza have not only been directly responsible for many of the cases under the head neurasthenia and functional paralysis, but also indirectly by weakening the nervous system, have made patients liable to many other forms of nervous disease, which, but for the antecedent influenza they would probably have escaped. The over pressure of the present day, the race among the lower middle classes and the poor not to get rich, but to escape poverty, and the financial disasters and frauds of the last few years, have all conduced to increase the number of cases of nervous diseases applying for treatment." (Queen Square Hospital Annual Report, 1894)
Quantitative data on neurasthenia from the annual reports
The prevalence of the diagnosis of neurasthenia as a proportion of total
discharges for the period under study is shown in
Fig. 1. The diagnosis makes its
first appearance in 1886, after which it follows a steep and almost linear
increase, peaking in 1906 at 11% of all discharges. There is a sharp fall from
this peak in 1908, the diagnosis averaging 7.4% of all discharges until
another sharp peak of 10% in 1920, and a further peak of 11% in 1928. This is
followed by an abrupt decline down to only 3% in 1930, and 1% in 1935 after
which it vanishes. The prevalence of the diagnosis was on a par with the major
organic categories treated, for example brain tumour, the prevalence of which
remained at between 5 and 10% of total discharges over the period of this
study. Figure 2 displays the
gender breakdown of the diagnosis of neurasthenia.
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Changes in the way in which functional disorders were classified over the period under study were all identified and are shown in Table 1. From its first appearance in 1886 neurasthenia appears as a separate category in every statistical return until it suddenly vanishes, and becomes a sub-category of the psychoneuroses in 1932. After 1941 neurasthenia disappears altogether and is not even a sub-category of the psychoneuroses (apart from one case in 1944). Figure 3 demonstrates the prevalence of all the psychoneurosis sub-categories in 1932 added together, including the now small neurasthenia category, and compares this with the prevalence of the earlier diagnosis of neurasthenia. From 1932 to 1944 the prevalence of the new psychoneurosis category averaged 7%, dropping to an average of 3% from 1945 to 1957, when the annual reports end.
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Examination of case records
Although the cases diagnosed as neurasthenia varied, a fact noted by other
investigators in this field (Shorter,
1992), they do contain the core symptoms outlined in the
introduction. See the Appendix for typical examples and for comparison
examples of cases with diagnoses of neurosis from the 1930s.
The patients with neurasthenia, like other Queen Square patients, were from the working classes, having occupations such as parlour maid, horn worker and crinoline and stay-maker. The diagnosis of neurasthenia was made regularly by all the consulting physicians.
Examination of the library historical collection
Reading of publications by consulting physicians at Queen Square reveals
that none had a specific academic interest in neurasthenia. Both Gowers
(1893) and Beevor
(1898) wrote neurology
textbooks within which they included sections on the diagnosis. Gowers devoted
one page to it in his first edition of 1888, and this had increased to six
pages in the second edition of 1893. He remains sceptical about the diagnosis,
suggesting that:
"there is no more justification for regarding neurasthenia as a definite malady...than there is for adopting a similar course with regard to debility" (Gowers, 1893: 1045).
Despite this he admits that "there are many cases for which it is a convenient designation" and goes on to give a detailed description of the syndrome. Kinnier-Wilson's Modern Problems in Neurology (Wilson, 1928) does not index neurasthenia, although the author was still making the diagnosis. There were no scientific papers published at Queen Square on the aetiology or treatment of neurasthenia. Instead, they seem to have relied on other authorities (mostly American). For example, the library contains specific texts on neurasthenia from the 19th century by Thomas Stretch Dowse (1892), Silas Weir Mitchell (1881, 1884) and Thomas Saville (1899).
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DISCUSSION |
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Social class and neurasthenia
The data presented in Fig. 1
contradict the myth outlined earlier that neurasthenia was a disease of the
wealthy classes, thus failing to support the first hypothesis. Queen Square, a
hospital providing charity treatment for the poor, treated large numbers of
cases of neurasthenia throughout the heyday of the diagnosis. The case-records
information on occupations of patients confirm that they were from the working
classes.
It is interesting that there is a lag of 17 years from Beard's first introduction of the term in 1869 to the first appearance of the diagnosis in Queen Square discharges. This may reflect the length of time it took the diagnosis to cross the Atlantic, as most of the references to it being the fashionable disease in Europe are from around the early 1890s (Wessely, 1996). Thus, it seems that it appeared and became prevalent in the working classes at about the same time as it was appearing in large numbers of their upper-class counterparts. This contradicts Wessely's (1996) suggestion that there was a gradual movement of the disease down the class structure. The textbooks in Queen Square library provide further evidence that physicians at the time observed that it was not only an upper-class disease. Thomas Saville (a London neurologist working at Paddington Infirmary) wrote in his Clinical Lectures on Neurasthenia (1899) about the frequency of the diagnosis among the poor and inmates of the Paddington workhouse (Saville, 1899). He made some epidemiological observations on the disease, comparing rates in these settings with those he encountered in his private practice, and concluded that there was no social-class trend.
Gender and neurasthenia
The data on gender in Fig. 2
dispel the second myth, that neurasthenia was largely a female illness, and so
do not support the second hypothesis. When the diagnosis first appears the
gender split is about 50/50, and even though the proportion of males falls to
a low in 1891-1905, it is never lower than about one-third. The male
prevalence then increases until there is a slight male excess in 1911-1915.
(This excess actually continues into the next 5-year time block until 1918,
but then a female excess returns so overall the period 1916-1920 shows a
slight female excess.) The increase in male neurasthenia during the war years
is almost certainly explained by its occurrence in servicemen returning from
the Western front. Between 1914 and 1918 one-third of the beds available at
the hospital were used for military cases (Queen Square Hospital Annual
Reports, 1914-18), and the medical registrars' reports comment on the high
frequency of functional disorders among this group. The number of males
affected just after the war is probably an underrepresentation, as in 1918 the
hospital opened a special house for the treatment of servicemen with
neurasthenia, and many more men would have been admitted there. However, the
war does not entirely explain the increased male prevalence of neurasthenia,
as it is already more common in men by 1910 (56% male, 44% female).
Disappearance of neurasthenia
Figure 1 gives a vivid
display of the rise and fall of neurasthenia. Particularly striking are its
abrupt appearance in 1886 and equally sudden disappearance after 1930. This
type of pattern might fit with a disease of infectious origin during an
epidemic, a possibility which cannot be entirely discounted. A major epidemic
of encephalitis lethargica swept across Europe in 1915, and some authorities
describe earlier epidemics (Brain,
1955). It is possible that neurasthenia represented a form fruste
of the disease, or a post-viral fatigue state following influenza epidemics.
The quote above from the annual reports indicates that doctors at the time
linked neurasthenia to influenza. It would be possible to trace the major
influenza epidemics in the 19th century to see if these related to the
fluctuations in neurasthenia, but this is beyond the scope of the current
paper.
An alternative explanation for the pattern seen is that it is due to changes in medical nosology. In Table 1 we see that although psychological categories came and went, they were not enduring and were never large, and so could not account for many cases. The abrupt fall in prevalence of neurasthenia in 1930 coincides with the reappearance of neurosis split into four sub-categories, which changes in 1932 into a bigger and enduring category of psychoneurosis split into 11 sub-categories, one of which is neurasthenia. Figure 3 illustrates that if all the psychoneurosis sub-categories in 1932 are added together they account for a similar proportion of total discharges (about 8%) which neurasthenia had accounted for previously. Thus, although neurasthenia apparently disappeared abruptly in 1932 apparently supporting Hypothesis 3, closer examination of the data has provided strong evidence that it was reclassified into the psychoneuroses, which continued to constitute just under one-tenth of all discharges. The case histories demonstrate that those with a diagnosis of neurosis in the 1930s had a symptom cluster common to earlier cases diagnosed as neurasthenia (see Appendix).
Did neurologists abandon neurasthenia?
The data presented here suggests that neurologists did not stop seeing and
admitting neurasthenia patients after 1900 thus Hypothesis 4 is not
supported. Contrary to Bynum's view, they had not handed neurasthenia over to
their psychiatric colleagues by the turn of the century, as the diagnosis was
made in at least 8% of the patients they admitted for three decades after
that. Even when it apparently disappears in the 1930s they were probably
continuing to see similar cases, but they were now making psychological
diagnoses. The reasons for the persistence of such cases in neurological
practice can only be speculated upon here. The asylums were only just
beginning to take an interest in the minor or neurotic mental
disorders in the 1920s; for example the Maudsley Outpatient Department did not
open until 1923 (Maudsley Hospital Annual
Report, 1924). There may well have been a shortage of suitably
trained psychiatrists, and the stigma of psychiatry as a speciality that dealt
with the insane may have created a reluctance in people to seek help in that
quarter. Although neurologists had clearly started making mental diagnoses at
Queen Square in the 1930s, it is an interesting question as to whether they
were using specific psychological treatments. This could be ascertained by a
more detailed study of the case records.
Examination of the case records confirmed that the diagnosis of neurasthenia was frequently made by all the consulting physicians. However, examination of the scientific writings of those same physicians demonstrates their lack of academic or research interest in the diagnosis. This confirms Wessely's suspicion that the academic disinterest of Queen Square physicians was not mirrored in their clinical practice. It seems that neurasthenia was not a very satisfying diagnosis to them, but it was a useful and pragmatic description of a large number of the patients who sought their advice.
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Clinical Implications and Limitations |
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LIMITATIONS
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APPENDIX |
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"Talk very nervous and excitable. Complains of mistiness of vision and palpitations and of general weakness, chiefly of both arms and right leg, right foot is very numb.... Does not drag right leg when walking. Complains of great pain in arm if she attempts any work. Ceased to menstruate 3 years ago. Has not been able to do any work for a year."
1891: 34-year-old female, no occupation. Sir D. Ferrier: diagnosis
neurasthenia
"Ill for past 22 months. Sudden onset January 1890 started out of bed with a vague feeling of fear, no pain, doctor came, temperature was 105... told she had influenza. Weak all over, in bed 3 days or more, and since then till time of pregnancy of last child October 1890 has been very delicate but able to attend her household duties, and go for short walks. During her pregnancy felt very weak. Often unable to walk to bed but no other symptoms except giddiness and a trembling in the legs. Has had no return of starting fits but feels very uneasy generally, is sleepless, irritated by small noises, but not restless. Feet always feel cold, suffers from palpitations. Bowels constipated."
1900: 25-year-old female, husband a labourer. Sir Gowers: diagnosis
neurasthenia
"Complaint: headache; backache; palpitations; indigestion; shortness of breath; pricking and jumping pains all over. Duration 3 years."
1925: 40-year-old male, office manager. Dr Howells: diagnosis
neurasthenia
"Complaint: Pressure in the head. Stabbing frontal and occipital headaches. Weak tired feeling. Tingling in arms and legs. Inability to concentrate. Restlessness, irritability and indecision. Insomnia. 6-7 years duration."
Cases of anxiety neurosis
1930: 34-year-old male clerk. Dr Holmes: diagnosis neurosis
"After the war age 30 went back to work as a clerk. Afraid of meeting people. Urgency which exacerbated it. Had to give up work. Ordered to bed for some time by his doctor. It was as if he had lost all his power and he could not walk more than fifty yards. When he got up he felt better but he was ordered to have 2 months rest. After this he went back to his work he felt much better and kept at work about 2 years before he got the next bad attack of nervous exhaustion after which he had to give up work for about 3 weeks. Since end December gradually worse. He had gradually lost his power more and more, but kept at work. When he came home in the evening he felt entirely exhausted and could not do anything but go to bed. He felt immensely tired and used all his spare time and weekends to lie down for rest. His sleep is all right but when he awakens in the morning he feels as if he has not had enough rest."
1935: 50-year-old female, husband warehouseman. Dr Holmes: diagnosis
anxiety neurosis
"Ill for 5 years. Complaint: Pain in left occipital region. Constant pain last 2 years in left occipital region and also at the vertex. Now cramp like in character and has affected the left side of the neck, so that she is unable to move her head without increasing the pain. Headaches are present 2-3 times per week. They consist of a generalised tight feeling all over the scalp and she feels as if machinery is going inside. She has become weak recently and is only able to do her housework with difficulty.Her legs ache after exercises and she tires easily. She is very emotional and becomes depressed over the slightest thing.
She cannot sleep at night. She says she feels as if she cannot manage to keep going."
1934: 59-year-old female, lace cutter. Dr Collier: diagnosis anxiety
neurosis
"Well until 4 years ago when she began to suffer from pain in the spine from the lower part of the neck right to the bottom.... Has been in the Nottingham General Hospital and had "all kinds of treatment" with absolutely no effect". Some 3 years ago she began to experience a feeling of coldness in her head, and this likewise has persisted... It is all over her head on both sides and is a combined sensation of numbness and coldness. Occasionally it pervades her face for a day or two.... At times too her tongue and throat feel cold and at other times they feel burning hot so much so that swallowing is painful. These symptoms have likewise not been benefited at all by treatment.... She feels weak all over and occasionally the use seems to go out of her left foot. Her legs feel numb and heavy and her hands and feet tingle and occasionally "go all scarlet".... Two years ago she had what she described as a "stroke". She went black and seemed to lose all power in her arms and legs for a few moments. She was completely restored by a little brandy."
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication July 26, 2000. Revision received November 20, 2000. Accepted for publication December 2, 2000.
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