The Framing of Neurasthenia

The diagnosis of neurasthenia evolved from its medical origin before disappearing in the early 20th century.

By Peter J. Koehler

“The history of psychiatry, more than any other branch of the medical sciences, is marked by the phenomenon of ‘rising’ and ‘falling’ diseases.” – Marc S. Micale.¹ 

In Part 1 of this series, “The Framing of Diseases Throughout History,” I discussed the concept of “hysteria” through the ages. The condition was already known in classical antiquity, albeit under a different name. Throughout history, it has been framed in different ways and in different contexts, eventually loosening its medical meaning and disappearing over the course of the 20th century. The term itself remained reserved for behavior that exhibits overwhelming or uncontrollable fear or emotional outbursts; in other words, it took on a nonmedical meaning as for instance in “mass hysteria” or “political hysteria.” 

In this second part, I will discuss neurasthenia or weak nerves. Although the remarkable statement above pertains to psychiatry, this article focuses on a condition that was initially regarded as an organic disorder. Moreover, it takes place in an era when neurology and psychiatry were practiced by a single specialist: a nerve-doctor or neuropsychiatrist. Let us first discuss a case study.

Marcel Proust (photograph by Otto Wegener, c. 1895); public domain.

A Famous Case

A nine-year-old French boy began experiencing episodes of “a choking sensation.” More episodes followed, especially in the spring. His parents consulted a doctor, Professor C., who, after conducting a differential diagnosis, ultimately concluded that the boy had asthma. In the 19th century, this had been considered a neurosis. 

As an adult, the person was believed to suffer not only from asthma, but also from sleep disorders. He appeared to be sensitive and had a heightened awareness. For some time, he was admitted to a sanatorium for neurotic persons as advised by Dr. S. At the age of 51, he thought he was having a stroke, from which his mother had suffered, and consulted Dr. B. It turned out, however, to be barbiturate intoxication. Not long after, he died of bronchitis. As it happened, his father had written a book in collaboration with a neuropsychiatrist on neurasthenia several decades earlier. After all, this was also the diagnosis that was applied to the patient.

Many of you may have recognized the patient as the famous author of the seven-volume novel “A la Recherche de Temps Perdu (Remembrance of Things Past)”(1913-1926), one of the two novels considered to be the best of the 20th century (the other being James Joyce’s “Ulysses,” 1922). We are talking about Marcel Proust (1871-1922) and his physician-neuropsychiatrist professor Jules Cottard (1840-1889; his name is associated with the Cottard delusion, in which the patient believes he is dead or does not exist), Paul Sollier (1861-1933), and last but not least, Joseph Babinski (1857-1932). 

Figure 1. Title page of Hygiène du Neurasthénique (1897); Wellcome Collection, public domain.

Weakening of Nerve Function 

Adrien Proust (1834-1903), Marcel’s father, a professor in the department of hygiene at the Paris Faculty of Medicine, and Charcot’s pupil, neuropsychiatrist Gilbert Ballet (1853-1916), had published “L’hygiène du Neurasthénique” in 1897 (See Figure 1), during a period in which the diagnosis neurasthenia had become fashionable. 

Although the term had been mentioned earlier in the 19th century, neurasthenia or nervous exhaustion was described by New York neurologist George M. Beard (1839-1883; see Figure 2) in an article in 1869 and more extensively in his monographs of 1880 (see Figure 3) and 1881.^2,3,4 The symptoms included:

• chronic fatigue and lack of energy
• headaches, often described as a throbbing sensation
• sleep problems or nonrestorative sleep
• difficulty concentrating and mental fatigue
• sensitivity to noise, light, or stimuli
• digestive problems
• heart palpitations or a feeling of weakness in the body
• irritability and emotional instability
• feelings of anxiety or a depressed mood

In general, it can be said that the diagnosis was based on vague symptoms that were difficult to assess objectively. It became a flexible diagnosis and a catchall term for a wide range of symptoms that were not easily explained from a medical standpoint.⁵

The new disease, however, had already been described in 1867 by Edwin Holmes Van Deusen (1828-1909), asylum physician of Michigan Asylum for the Insane in Kalamazoo, Michigan.⁶ He wrote: “As to the term neurasthenia, it is an old term, taken from the medical vocabulary, and used simply because it seemed more nearly than any other to express the character of the disorder and more definite, perhaps, than the usual term ‘nervous prostration.’” 

Figure 2. George Miller Beard; National Library of Medicine, digital collections, public domain (NLM Image ID: B02556).

Indeed, the term “neurasthenia” can already be found in the fifth edition of Robley Dunglison’s “Dictionary of Medical Science” (1845). In the 13th edition of 1856, we find the following description: “Debility or impaired activity of the nerves.” Thanks to Beard’s post in New York and his in-depth research into what he initially called the “American disease,” he was hailed as the discoverer of the new disease, soon to become fashionable. He visited various institutions and gave lectures in Europe, after which he wrote an article on the subject.⁷ 

Neurasthenia spread to Europe where it found fertile ground, particularly in France and Germany, and to a much lesser extent in England and the Netherlands. In Paris, Charcot believed Beard’s 1880 book was a remarkable monograph. Neurasthenic patients accounted for most of the neurological cases he saw in his private practice, and he found them unbearable, writing “Poor Beard.”⁸ 

In his book on neurasthenia, German psychiatrist Rudolf Arndt (1835-1900) was critical, calling it “Yankeekrankheit.” He wrote: “Die Krankheit ist immer dagewesen; sie hat nur den Namen gewechselt (The disease has always been around; it has simply changed its name).”⁹ Franz Carl Müller (1860-1913), director of a water spa, even published a “Handbuch der Neurasthenie” (1893).¹⁰

Figure 3. Title page of Beard’s 1880 monograph; Wellcome Collection, public domain.

In England, reactions were mixed; there were both supporters and opponents. Thomas Stretch Dowse (1832-1912) published “On Brain and Nerve Exhaustion (Neurasthenia) and on the Nervous Sequelae of Influenza” (1894).¹¹ Others were critical, arguing that it was simply old wine in new bottles and that it was not limited to a particular social class.

Beard’s most important sources for the new disease concept were English physiologist Marshall Hall’s (1790-1856) spinal reflex activity (1833), German physiologist Emile Dubois Reymond’s (1818-1896) discovery of the action potential (1848), and American inventor Thomas Edison’s (1847-1931) work on electricity. Medical electricity had been the subject of Beard’s monograph about a decade earlier: “A Practical Treatise on the Medical and Surgical Uses of Electricity: Including Localized and General Electrization” (1871).¹²

The concept of neurasthenia was linked to new insights in the field of thermodynamics, including the law of conservation of energy. It was believed that overwork, along with toxic, metabolic, and infectious diseases, could cause the condition. Modern civilization — including the telegraph, science, the steam engine, newspapers, and education for women — played an important role. 

The diagnosis was primarily made among highly educated individuals and city dwellers, particularly successful men. Beard believed that if it was not treated, it could lead to prolonged depressive mood, chronic physical symptoms, social withdrawal, reduced work productivity, and increased susceptibility to other illnesses. Treatment, he believed, should include rest and recovery, change of scenery, proper nutrition, physical activity, electrical therapy, and psychological support.

From Social to Psychological Etiology

Initially, it was believed that neurasthenia was an organic disorder of the central nervous system and, as mentioned, occurred primarily in highly educated individuals. Businesspeople, doctors, and writers alike could fall victim to it. Several other writers besides Marcel Proust are known to have suffered from neurasthenia and to have written about such characters in their novels (including Henry James (1843-1916), Edith Wharton (1862-1937), and Virginia Woolf (1882-1941)). 

However, as fatigue was difficult to measure and the disease lacked neuropathological findings, the organic origin became problematic around 1910. During that period, the disease was gradually diagnosed in people from lower socioeconomic backgrounds, in women, and in immigrants as well. It was no longer “the American disease.” 

These factors gradually paved the way for a psychological explanation of the condition. Psychological symptoms were no longer considered the result but became a cause. In the meantime, several clinical syndromes branched off from neurasthenia, including anxiety neurosis (Sigmund Freud (1856-1939)) and obsessive-compulsive disorder (psychasthenia, Pierre Janet (1859-1947)).¹³ Whereas rest cures, drug treatments, and electrostimulation had previously been used — when the illness was still considered an organic condition — these treatments were now replaced by psychotherapy, and rest cures were regarded as harmful. The role of suggestion was recognized, and the relationship between patient and doctor took on greater significance.

Neuropsychiatrists in City Practices

During this period, a significant sociocultural phenomenon emerged in many countries. The idea arose that patients with mental disorders who required institutionalization — mostly patients who would be considered psychotic today — should be distinguished from “nervous” patients who posed no danger to society or to themselves. This phenomenon was not only in the interest of patients because of the stigma of insanity, but also of the physicians who treated them. 

These patients suffered from “nerves” or were “nervous” and needed rest or a course of cold-water therapy. They could be admitted to new types of institutions, sanatoria, rather than lunatic asylums. (The name of the latter gradually changed to “psychiatric hospitals” or “psychiatric institutions.”) This division meant that alienists, psychiatrists, and neurologists had the opportunity to establish their own successful practices in the city. For many doctors, this also meant an improvement in their social status.

When it gradually became clear that the disease had a psychological, rather than organic origin, there were still neurologists who claimed that techniques to identify changes in the nervous system were still lacking but would become available in the future. In 1927, one-third of American neurologists were still treating patients with neurasthenia or psychasthenia. That same year, the renowned Swiss-American psychiatrist Adolf Meyer (1866-1950) lamented the fact that American doctors, and neurologists in particular, were still treating patients with neurasthenia. They were reluctant to abandon the diagnosis and clung to the idea of an organic cause. 

Disappearance of Neurasthenia 

After the first decades of the 20th century, the diagnosis neurasthenia gradually disappeared. The rest cure seemed to offer no relief, and the illness became increasingly common among the lower social classes rather than the upper ones. Neurologists no longer treated these patients, and the condition was considered rare, particularly in England. 

When the illness was still regarded as physical in nature, doctors showed more understanding toward their affluent patients who were overworked, but now they were no longer “interesting.” It is likely that most patients who were previously diagnosed with neurasthenia were subsequently diagnosed with depression. The gradual disappearance can be followed in various editions of “Cecil Textbook of Medicine,” in which the text on the subject changed from one chapter (first edition of 1927) to one sentence (seventh edition of 1947). Another problem was that when the illness was considered psychological in nature, it was often viewed as “not real” in contrast to physical ailments.¹³ 

It is interesting to observe that the rise and fall of neurasthenia coincided with first-wave feminism (1870-1920). As mentioned above, several aspects of modernity were believed to play a role in the almost epidemic increase in the prevalence of neurasthenia. One of these was the role of women who demanded the right to vote in elections (woman’s suffrage), education, and divorce. 

Several medical historians, however, have argued that it may have been just the name of the diagnosis that disappeared. They refer to subsequent diagnoses including chronic brucellosis (1950s), chronic Epstein-Barr infection, post-viral fatigue syndrome, and myalgic encephalitis.¹³ 

If we look at nosographical systems of the 19th century, we see that the diagnosis was still present in Diagnostic and Statistical Manual: Mental Disorders (DSM) I to III (1952-1980), but had disappeared from the DSM-III-R (1987). As for the International Classification of Disease (ICD), it was found from ICD-2 (1909) up to ICD-10 (1992). In ICD-3-5 (1920-1938), it was called “hysterical neurasthenia.” It was considered outdated in ICD-11 (2020). We must bear in mind that the World Health Organization (WHO) adopted ICD-6 in 1948.

Figure 4. Neurasthenia frequency and number of pages in Ned Tijdschr Geneeskd (1857-2005).

Neurasthenia in Historic Medical Journals and Newspapers

The rise and fall of neurasthenia can also be followed in medical journals as well as in newspapers. As for medical journals, it was possible to do a bibliometric search of the Dutch general medicine journal Nederlands Tijschrift voor Geneeskunde (Dutch Journal of Medicine) that was founded in 1857. (See Figure 4.) Between 1857 and 2005, the term appeared 1,654 times, first appearing in 1882. 

The New England Journal of Medicine (Boston Medical and Surgical Journal before 1928) has 1,420 entries between 1869 and 2024. This search yields 71 pages, with 20 references per page. The last three pages cover the period between 1941 and 2024, which means that most of the articles were published between 1870 and 1940. I expect the graph to be like that of the Dutch journal.

Figure 5. Neurasthenia frequency in Dutch newspapers.

Figure 6. Number of hits with the term “neurasthenia” in Collection Chronicling America of Historic American Newspapers between 1870 and 1949.23

As for newspapers, I searched the database of Dutch newspapers (Delpher,¹⁴ a website with a collection of over 2 million newspapers from the Netherlands, the Dutch East Indies, the Antilles, the U.S., and Suriname from the period of 1618 through 1995) and the collection Chronicling America: Historic American Newspapers at the Library of Congress. (See Figures 5 and 6.)¹⁵ The American database yielded 41,551 results (20,971 pages) from the period 1870-1949. The Dutch database contained 28,779 articles and advertisements (1870-1995). Some of the advertisements we find in these historical newspapers are interesting. (See Figures 7 and 8.)

Weak Nerves in the 18th century — the English Malady

Figure 7. Illustration above an article in the New York Herald of March 25, 1906.²⁴

It is interesting to note that if you search for the terms “weak nerves” or “nervous weakness” in American historical newspapers, you get many more results (1.4 million). Furthermore, the first result for “weak nerves” dates to 1767. It is a “letter to the printer” in The New-Hampshire Gazette and Historical Chronicle from December 1767, written by a certain doctor named Trahlur: 

“I was present yesterday at the complaints of a patient, whose physician attributed them all to tea; and added, that few persons ought to drink tea after the age of 40; few at any age. A weak stomach, trembling limbs, giddy head, relaxed nerves, miserable low spirits, want of appetite, and universal langour, What a train of evils do arise from so paltry an indulgence. Is it not strange, Sir, that we cannot imitate our rational neighbourhood of the North? At Upsal, they drink a tea of select-herbs of their own growth; and there is scarce a weak man, or a man of weak nerves among them. I am, Sir, Your humble fervent, Trahlur.” (See Figure 9.)¹⁶ 

Figure 8. Advertisement for a tonic to prevent neurasthenia in The New Haven Union of March 1, 1906.²⁵

Apparently, the doctor criticized by the letter’s author believed that tea had a relaxing effect in the sense that it weakened the nerves.

In the 18th century, the word “nervous” had positive connotations, implying, among other things, strength, decisiveness, and the absence of weakness.¹⁷ Conditions such as melancholia, vapeurs, “hysteria,” and hypochondria were believed to have a neurological cause. An important book from this period was “The English Malady” by physician George Cheyne (1672-1743). Diseases resulting from overconsumption and a sedentary lifestyle were attributed to the central nervous system. 

Figure 9. “Letter to the Printer” in The New-Hampshire Gazette and Historical Chronicle of Dec. 11, 1767. ²⁶

In “Diseases of Civilization and Nervous Disorders in the Age of Enlightenment,” (World Neurology, June/July 2020), I wrote that, at the time, the term “nervousness” was fashionable for physicians as well as patients. The well-known medical historian Roy Porter (1946-2002) noted “‘Nervous’ maladies became privileged in polite society, as tokens of their victims’ cultivation, and ‘nervousness’ turned into a badge of honor, a mark of superior sensibility.”¹⁸ It was thought to be observed in particular in intelligent and rich people. 

Although Beard, when writing about neurasthenia or “American nervousness,” did not refer to the “English malady” of the previous century. The two conditions have much in common. The comparison cannot be better worded than in this conclusion of Porter’s chapter: 

“Sufferers from the English malady were said to have succumbed to profound anxiety because they were engaged in the performance of glamorous, if taxing, parts on the Spectatorial stage of fashionable society; the disorder was thus the product of affluence, politeness and excess. A century later, neurasthenics were said to develop exhaustion and depression because they constituted an ambitious elite living in the fast lane in an economic system whose law was [a] struggle. The English malady was a refinement of the old pathology of luxury; American nervousness was a disease of labor. The malaise of the bon ton had given way to the disorder of the businessman.”¹⁸

Summary and Conclusions

In the 18th century, when figures such as Robert Whytt (1714-1766) demonstrated that the nervous system plays a significant role in many diseases, and when the term “neurosis” was coined by his student William Cullen (1710-1790), a common clinical condition known as “nervousness” emerged. 

The notion of “weak nerves” persisted throughout the 19th century; it was described by Beard as a new condition in the late 1860s and became widely accepted by the 1880s. Initially, it was believed to be an organic disorder that primarily affected men in the upper social classes. The concept had advantages for both patients (avoiding the stigma of being considered insane) and for the various practitioners (private practices in the city; the term “neurasthenia business” has been used).¹⁹ 

Gradually, in the early 20th century, it became clear that the disorder also occurred in other social classes and that the cause was psychological rather than organic. The diagnostic concept disappeared after it was subdivided into anxiety neurosis, psychasthenia, and depression. One might wonder to what extent there is a connection with various conditions exhibiting similar symptoms that emerged in the following century and for which no cause is known.^20,21,22 

For both “hysteria,” as discussed in the first article of this series, and neurasthenia, it is true that not only biological factors, but also social and cultural factors played an important role in the emergence and disappearance of these conditions. Language, culture, and perhaps also power played a role in this. 

As mentioned in Part 1, both “hysteria” and neurasthenia can be cited as examples of the fact that diseases are not immutable natural phenomena, but socially and culturally constructed concepts. They reflect contemporary medical knowledge, moral values, and social norms. Diagnoses may eventually become obsolete due to new insights, or they may no longer align with certain societal views regarding health and illness.

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