Joseph Lockhart
Saty Satya-Murti
Santa Maria, California, United States

The history of neurasthenia up to 1919

Physician George Beard (1839–1883) introduced the term neurasthenia¹ as a popular construct to the United States, publishing his book American Nervousness in 1881.² The disorder was seen as a peculiarly American illness, brought on by rapid changes in modernization and the replacement of manual with intellectual labor. A weak point of the neurasthenia diagnosis was its lack of specificity. Beard’s list of potential neurasthenic symptoms went on for several pages, including even rapid tooth decay as a possible consequence. Yet, this fuzzy grouping of diverse symptoms proved to be one of the chief advantages of the diagnosis when used to conceal a U.S. President’s severe illness.

Over time, most experts agreed the core symptoms of neurasthenia included: feelings of disproportionate physical exhaustion following mental exertion; difficulty concentrating and remembering; mild depression; and areas of non-specific pain and tenderness.³ In terms of etiology, neurasthenia was believed to result from exhaustion of an individual’s quantity of “nervous energy,” usually by mental overwork or pressures associated with the demands of modern industrialized society. Although women were typical sufferers, men who engaged in “cerebral” work were also likely to fall prey to “nervous prostration.”

Initially, the disorder was seen as primarily afflicting those of the upper class, whose daily lives involved mental stresses and strains. Both William James and Jane Addams were diagnosed with the disorder.⁴ Popular portrayals of neurasthenia in the press were common, and likely did much to normalize the disorder. O. Henry wrote a humorous semi-autobiographical story about himself⁵ titled “Adventures in neurasthenia.”

Over time, it became accepted that all social classes could suffer from neurasthenia. Some physicians⁶ placed the blame on “overcivilization,” a problem deemed especially rampant in the rapidly evolving United States. By the turn of the century, it was a common diagnosis for patients with diverse complaints, and also a way to sell “rest cures” and patent medicines. Perhaps a perverse pride at owning a national disorder removed the last vestiges of stigma, and advertisements for the treatment of neurasthenia were proudly announced in many newspapers. The Rexall drug chain introduced an elixir of alcohol and chloroform called “Americanitis” in honor of the root cause of suffering (Figure 1).

Early tensions over neurasthenia treatment

As a purported “nerve disorder” with emotional overtones, neurasthenia inhabited a gray area between neurology and psychiatry.⁷ At this time psychiatrists (known as “alienists”) primarily practiced in asylums with severely mentally ill patients. The term neurasthenia suggested a primary role for neurologists, a comparatively small specialty at the time.⁴ Unlike alienists, neurologists had outpatient and community hospital practices, and neurasthenia was viewed far less negatively than insanity. Similarly, its symptoms were caused by a lack of “nerve force” as opposed to mental illness, which was usually assumed to be hereditary and progressive.

The extraordinarily broad diagnostic criteria suggested by Beard engendered friction between the early psychiatrists and neurologists who came down on opposite sides in their attempts to narrow the diagnosis. Some psychiatrists suggested neurasthenia was likely a milder or early form of mental disease,⁸ and that sufferers would almost inevitably progress on to insanity and asylum. Frank Norbury (1863–1939), a well-respected neurologist, went to the opposite extreme, arguing that melancholic and neurasthenic symptoms were caused by nutritional deficiencies at the neuronal level, and thus squarely within the purview of the neurologist.⁹

Treatment of neurasthenia involved a drastic change of scenery for the patient: placement in a sanitarium, with initial complete bed rest and a diet consisting of huge amounts of milk and fat.¹⁰ There was to be no mental activity while the nervous energy recharged; even pastimes such as reading were forbidden. In her story “The Yellow Wallpaper,” author Charlotte Gilman¹¹ wrote about the severe mental toll such isolation could have. As the patient improved, light work outdoors was permitted.

Of course, this meant that treatment was limited to only wealthy or otherwise privileged patients (Figure 2). This was recognized as an issue of concern, leading to a call for neurologists¹² to develop community-based treatment facilities for the less well-off. Physicians of the time recognized that there were significant psychological aspects of neurasthenia. Some recommended the use of both direct suggestion (borrowed from hypnosis) and the importance of communicating a positive attitude that the patient was improving.¹³

Woodrow Wilson’s health crisis

One of the most significant and controversial uses of the neurasthenia diagnosis was carried out via newspaper articles in 1919 to 1920, attempting to conceal President Woodrow Wilson’s multiple strokes.¹⁴ Wilson had suffered two strokes, one in late September and a second on October 1, 1919, resulting in left hemiplegia, hemianopsia, and unconsciousness. These strokes required an abrupt cancellation of his speaking tour and all presidential activities. Eminent neurologists including S. Weir Mitchell and Francis Dercum consulted on his case.

The unprecedented and tense international situation may explain the White House’s desire to invoke neurasthenia as a pretextual diagnosis for Wilson’s stroke. The first World War had ended less than a year before, and Wilson’s plans for acceptance of the Treaty of Versailles and launch of the League of Nations awaited Senate ratification.

While his Cabinet, Congress, and the American public deserved to learn about Wilson’s neurological incapacity, such a revelation could have extinguished any hopes for ratification, effectively aborting the formation of the Treaty and the League. Decisions with grave consequences faced the President, his physician and friend Dr. Cary Grayson, Chief of Staff Joseph Tumulty, and the President’s wife, Edith Wilson.^15,16 Over the first few days, as Wilson regained consciousness and stabilized, it became clear that his non-dominant hemispheric stroke had spared his language, humor, and ability to express his wishes.

During the next three months, little was shared with the public or even the Senate and foreign leaders. Secretary of State Robert Lansing was fired for attempting to address the issue, and the White House effectively concealed any revelation of the true and serious nature of Wilson’s illness.^17,18 Post-infarct edema, uncal herniation, seizures, aspiration pneumonia, or sepsis could all have followed the initial event. Fortunately, none of these complications, except for bladder problems, transpired. It might have seemed prudent to have initiated the Presidential succession sequence, but this was not to be. The nation remained uninformed.

The challenge to insiders

The trio of Dr. Grayson, Tumulty, and Mrs. Wilson decided to minimize the gravity of Wilson’s neurological disability. Using a pretext of preserving Executive control and political resolve, along with patient-physician confidentiality, the decision was made to blame his “nervous prostration” on the more benign disease of neurasthenia. In the initial newspaper releases, the highly worrisome withdrawal from public life was attributed to a bout of influenza, which had depleted the President’s nerve energy and caused his nervous prostration (Figure 3).¹⁴

In keeping with the neurological practice of that period,¹⁹ this virtuous diagnosis, although clearly a falsehood and denial, served its purpose admirably. Nervous exhaustion and fatigue, as a diagnosis, would evoke a benign mental image. It would generate sympathy, explaining the need for rest from the unrelenting pressures of office. In the midst of a potential international crisis, neurasthenia stood to gain far better acceptance than paralysis, blindness, stroke, or organic brain disease.

Indeed, this is the diagnosis that most newspaper columns carried; a few (including Dr. Dercum) denied outright any contrary possibilities (figure 4) such as an “organic disease” or a “cerebral lesion.”^20,21 By January of 1920, minimal information about the true nature of his stroke was beginning to leak out to the press, but even later articles continued to blame neurasthenia as the primary cause. The newspapers celebrated when, a few months later, Wilson was hailed as having fully recovered from his “slight impairment.”²² In reality, he was rarely well enough to appear in public until after his term ended in March of 1921.

The decline (and rebirth) of neurasthenia in the 1930s and beyond

The decline of neurasthenia as a diagnosis coincided with the rise of Freudian psychoanalysis in the 1920s, another system with limited empirical support.⁴ Psychiatry claimed the neurasthenic for themselves under the rubric of psychoneuroses, while neurologists turned their focus to more clearly organic diseases.

Neurasthenia was ultimately dropped as a diagnosis from the International Classification of Diseases, 11^th edition (ICD-11) in 2018. However, until recently, it remained a popular diagnosis in China,²³ and some have suggested its sufferers are now diagnosed with myalgic encephalomyelitis or chronic fatigue syndrome.²⁴

Conclusions

Even in the present day, questions and controversy arise regarding the topic of how much the public should be told about an ailing President’s health and limitations.^25,26 Some authors have suggested that President Biden’s inner circle attempted to carefully orchestrate his public interactions to mask a serious cognitive decline, thereby influencing the course of the election.²⁷ Others have wondered if President Trump’s staff is adequately transparent regarding his cognitive or mental health.²⁸

We will never know what alternate course history might have taken if the true nature of Wilson’s illness had been revealed to the public in the fall of 1919. Although we should avoid retrospective bias, and even give the benefit of doubt to the Executive Office and inner circle, it is clear they chose to misinform the nation using the pretext of neurasthenia.

References

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