The Patient Interview, Part II: Nerves
The Patient Interview, Part II: Nerves

The Patient Interview, Part II: Nerves

“Nervous” is a term Mrs. Jones uses and applies to herself from the beginning of the examination to its end.  Before she was admitted to Dix, she spent a week at a private sanitorium in Raleigh.  Asked by Dr. Anderson why she sought treatment there she replies: “I was nervous, restless, and couldn’t be still.”  There was only one other female patient there that week, a Mrs. Wright.  Dr. Anderson asks about her:

Q. Was she nervous?

A. Yes sir.

Q. Was there anything wrong with her mind?

A. Yes sir.

The reason she gives for going to see a local physician was because she was nervous, and “didn’t know what was the cause of my nervousness.”  He told her to stop worrying and prescribed castor oil.   She speculates that perhaps doctors should not tell “nervous people” what is wrong with them—it just makes them more nervous.  After her examination, she was nervous “over my mother and sister and the blood pressure.”

One of the supposed causes for her attack of insanity was listed as “child birth,” and Mrs. Jones is questioned about any “sickness” after the baby was born.  She answers that she was nervous after the baby was born.  However, later she says she was also nervous before the birth.

Patients at the asylum were expected to engage in regular productive activities.  This was in part a legacy of the moral treatment philosophy upon which the asylum movement was founded in the middle decades of the nineteenth century.  However, patients also provided free labor for the asylum.  Male patients worked in the garden and tended livestock; female patients sewed and worked in the laundry.  In her final statement to the doctors, Mrs. Jones uses “nervous” to describe her anxiety over not feeling able to do the work assigned to her.  “I am nervous because I have these pains when I try to work and when I work seems like my eyes are straining, and when I say anything about going home some of them tell me that I won’t go home because I don’t work.”

Mrs. Jones was hardly alone in reaching for the term “nervous” to characterize her feelings.  Across some 128 North Carolina newspapers in 1916, it appears more than 9000 times.  In Anxiety: A Short History (Baltimore: Johns Hopkins Univ. Press, 2013), Allen Horwitz demonstrates how both anxiety and nervousness become part of medical, psychiatric, and neurological discourse in the second half of the nineteenth century.  The credit for making nervousness and nervous exhaustion part of the “office furniture” of American doctors by the 1890s is usually given to neurologist George Beard.  In the 1860s and 1870s, Beard was among many American doctors confronted by otherwise healthy men and women complaining of a wide array of debilitating emotional, physical, social, and sexual ailments for which no specific cause could be determined.  In some the condition led to a profound state of exhaustion.

Prevailing psychiatric theory accounted for them as symptoms of hysteria or hypochondriasis—products of the sufferer’s mind and without somatic foundation.  In an 1869 article which became the basis for his groundbreaking 1881 treatise, American Nervousness: Its Causes and Consequences,  Beard argued that there was a somatic basis for this syndrome, which he named “neurasthenia,” but not it was not a function of organic or infectious disease.  Rather, psychic and emotional exhaustion reflected a drastic depletion of nervous energy.  Nervous exhaustion affected other somatic systems and could be responsible for—among other ailments–indigestion, muscle pain, impotence and infertility, depression, irritability, and chronic fatigue.

Of course, this analysis begged the questions of what caused the draining of nervous energy in the first place and whether there were some people who were more susceptible to neurasthenia than others.  Beard and his fellow neurologist S. Weir Mitchell observed that professional men and socially active women were most subject to neurasthenia, and hypothesized that they were more likely to experience the stresses, competition, and uncertainties of modern urban life.  As David Schuster puts it in his 2003 JAMA article on “Neurasthenia and a Modernizing America,” “For Beard and Mitchell, neurasthenic patients were casualties of modern society whose bodies and minds simply could not keep up with the seemingly accelerated lifestyles of men and women in the latter part of the 19th century.”  These social types were, Beard argued, quintessentially American, and so, in turn, was the condition from which they suffered—hence American Nervousness.

Doctors of various stripes and qualifications developed treatment regimens for restoring nervous energy and mitigating the effects of modernity on affluent cosmopolites.  Not surprisingly, these usually involved some form of pastoral rest cure.  Mitchell believed that a fatty diet combined with six weeks of bed rest replenished the body’s store of nervous energy.   For sufferers not able to afford such retreats, local doctors offered a range of temporary treatments in their offices (including electric shock therapy), and recommended eating fresh vegetables, rural vacations, and giving up alcohol.  Mrs. Smith was prescribed castor oil and told to get plenty of outdoor exercise.

Members of the social and intellectual elite on both sides of the Atlantic “came out” as neurasthenics, including both William and Henry James, sociologist Max Weber, feminist writer Charlotte Perkins Gilman, and novelists Theodore Dreiser and Thomas Mann.   Neurasthenia, nervousness, nervous exhaustion, and nervous breakdown all infiltrated popular discourse, and by 1906 had becomes household words. (Schuster, p. 2328).

Beard gave a name to a broad and vague complex of pains, anxieties, fatigue, and feelings—neurasthenia–and, in doing so, pointed both to the somatic system from which he claimed they arose (the nervous system) and to the field of medicine devoted to its study (neurologists).  Nervous and nervousness, which had been a part of popular discourse long before the publication of Beard’s theories, became medicalized as well—a way of connecting the experience of illness with a “real” disease and the part of the body responsible for it.  Several other conditions were propagated from “nervous” and became a part of the vernacular discourse by the beginning of the 20th century: nervous dyspepsia, nervous headaches, nervous prostration, nervous exhaustion, “nerves on edge,” “nervous wreck,” nervous strain, and nervous breakdown.

The first use of the term “nervous breakdown” that I can find in a North Carolina newspaper comes in 1887.  The Wilson Mirror (Wilson, NC) ran a wire service article by George Rohe, MD, entitled “Neurasthenia: Characteristic Disease of Modern Civilization” (Oct. 5, 1887).  It explained the origins and development of the condition following Beard’s book (which earned it “rightful citizenship in the medical vocabulary”) and assigned it to such iconic figures as Thomas Carlyle, Victor Hugo and Richard Wagner.  One form of the condition does not manifest itself until middle age, he wrote, when “owing, perhaps to some extra strain, the nervous system gives way,” producing in the professional man a “nervous breakdown”—a reminder that he cannot get “a three-minute gait out of a four-minute horse.”

A half century before Beard introduced the term neurasthenia to the American medical community, “nervous disorder” was already being used in the popular press to account for a range of conditions, including consumption, lowness of spirit, impurity of the blood, loss of appetite, indigestion, melancholy, and pains in the limbs.  The term was adopted not by doctors, but by the manufacturers and advertisers of patent medicines.  Readers of the Weekly Raleigh Register on November 3, 1815 learned about Hamilton’s Grand Restorative, as a cure for all the above complaints.  The ad also located their cause in a debilitated nervous system, which this tonic “braces, without stimulating too violently.”

Virtually every local newspaper carried advertisements for a wide variety of lotions, tonics, nostrums, powders, and pills–nervous cordials, universal neuralgic pills, women’s tonics, cephalic pills for nervous headaches, and Dr. Hostetter’s Stomach Bitters.    Some of them were obtained from the doctor who purportedly concocted them:

Miss P. of the county of Halifax, N.C., a young lady who has for many years suffered with nervous headache, and could obtain but little relief from the remedies generally resorted to.  I was requested by her father to try my mode of treatment to her case, I did so, and in a few moments she was relieved.

More commonly, however, they were available from a local druggist.  In 1842, some 37 different patent medicines were carried by a drug store in New Bern, N.C., along with blue pill (mercury), digitalis, opium, and strychnine.  At a time when the training and skills of medical doctors (particularly outside of large cities) were rudimentary and their treatment options few and of uncertain efficacy, patent medicine manufacturers, newspapers, and druggists combined to create a treatment alternative.   Patent medicines were sold without a prescription, and until the passage of pure food and drug legislation in 1906, ingredients (which might have included alcohol, opium, and/or laudanum) were not required to be identified—indeed, they were regarded as proprietary secrets.  Newspaper ads gave names to “a great many of our most aggrevated maladies,” and announced a cure for them at the same time.  The system challenged the authority of the traditional medical community.  Testimonial cases were recounted in the ads, frequently crediting the tonic with restoring health when doctors had failed to do so.

There was a class and racial bias to Beard’s identification of the likely neurasthenic: professional high-flyers, aesthetes, and social butterflies.   Dr. Pierce’s Favorite Prescription for Women was unquestioningly democratic, offering relief for the over-worked, worn-out, and run-down; the debilitated teachers, milliners, dressmakers, seamstresses, shop-girls, housekeepers, nursing mothers, and feeble women. (North Carolinian [Elizabeth City, NC], Jan. 15, 1890.

Dr. Pierce called his tonic “a soothing and strengthening nervine.”  By this time (1890) the term “nervine” had been established for decades as the generic name given a nostrum designed to treat anything that could be described as a nervous condition.  It appears in North Carolina newspapers as early as 1841 (Dr. Harrell’s Nervine Lotion).  But it becomes most associated with the products of a company that survived well into the 20th century.  In 1885 an Indiana doctor Frank Miles launched a tonic, Dr. Miles’ Nervine, which claimed to cure nervous prostration, sleeplessness, St. Vitus Dance, fits and spasms.  (Wilmington Messenger, Dec. 6, 1890).  By 1890 ads for the product had become staples in local newspapers.

In large measure, Dr. Miles’ Nervine owed its success to lavish advertising, which drew upon strategies developed in the hawking of other patent medicines: a memorable product name, pictorial symbols, and a consistent type face, among them.  Many products used celebrity testimonials.  Miles built self-congratulatory narratives around testimonials from satisfied customers.  In the spring of 1890 a Mr. P. W. Hebebrand’s woodcut image appeared in papers around the country under which he proclaimed “I am satisfied Dr. Miles’ Nervine saved my life.  I was a nervous wreck and unable to attend to my business.  Doctors failed to benefit me and I decided to try Dr. Miles’ Nervine.  It gave me prompt relief and finally effected a complete cure.  I am in good health and have gained several pounds in flesh.”  (Asheville Daily Gazette, April 20, 1900)

A female minister told of suffering extreme exhaustion, which made it impossible for her to work.  Her nerves were “on edge.”  Thanks to Dr. Miles’ Nervine, she was restored to good health.  A mother gave it to her fourteen-year-old son suffering from a “terrible nervous affliction,” which resulted in his losing her power of speech and use of his limbs.  One bottle of Nervine restored his speech; five bottles cured him entirely.   Miles also offered free samples (available at druggist or by mail for ten cents) and the money-back guarantee on the first bottle purchased.

By the time Mrs. Jones used the term “nervous” to describe her feelings to the Dix Hospital doctors, the standard advertisement for Nervine had adapted a mode of engagement from Hollywood cinema.  The ad constructs its intended viewer in its address to “Every Housewife or Mother [who] is ever under that Nervous Strain. . . .”  It represents her pictorially in this role, slumped over a treadle sewing machine, a forlorn child at her feet, calling the viewer into a world and predicament she can identify with.   The ad makes her into a character (in this case a “real” woman: Mrs. Frances Whitlock) who tells the viewer the story precipitated by her plight.   We see her when she had become “greatly run down” and with her nerves “in terrible condition.”  As her pose suggests, she had frequent headaches, was weak and “unable to do anything.”  The ad then makes her the protagonist of her own story.  What could she do?  Her decision to buy a bottle of Dr. Miles’ Nervine moves the story from tragedy to comedy: “I soon began to feel better; my nerves were quieted.”  The ad invites us to imagine Mrs. Whitlock in her current, recovered state, and as the agent of her friends’ improved health.  Newspaper readers would have been accustomed to seeing dialogue in films rendered as written speech.  Until the late 1920s movies were silent and relied upon what were called intertitles or title cards inserted between shots for characters’ direct speech and internal monologue.  They also conveyed third-person narration.

Mrs. Whitlock models (in both senses of the word) what we might today see as a kind of domestic feminine agency.   She is responsible for the running of the house and the care of her children.  She recognizes the signs of overwork and stress and their impact on her effectiveness.  She takes it upon herself to find and acquire a remedy and advises her friends who might also suffer from nervousness.

We should also note who is not depicted in this ad nor is a character in Mrs. Whitlock’s narrative.   Although the protagonist is Mrs. Whitlock, Mr. Whitlock is absent.  In an ad from the 1930s, however, it is the husband who is addressed.  His “problem” is having a wife with “over-wrought nerves,” which make her “irritable, impatient, ‘hard to get along with.’”  It is no fun for him to live with a woman with “NERVES.”  He is the one shown taking action to remedy his wife’s ailment.  Interestingly, however, the address shifts in the middle of the ad to the wife: “When you feel yourself worrying over trifles, startling at sudden noises, irritable, wakeful, ‘keyed-up’—the first place to look for the cause is your nerves—and it’s best not to neglect them.  Nervous troubles seldom correct themselves.”

It is also telling that Mrs. Whitford did not consult her doctor, or, for that matter that the husband with the nervous wife did not suggest taking her to a doctor.  Doctors seldom appear in ads for nervine and other patent medicines except as medical professionals who have failed to provide relief for the sufferer, thus precipitating her need for alternative treatment.  Indeed patent medicines represent a way for people (particularly women) to self-medicate without having to present their symptoms to a doctor.  The druggist takes the place of the doctor in this therapeutic circuit, which connects the pharmaceutical industry, advertising industry, pharmacists, and consumers.  “Dr. Miles” plays the symbolic role of the doctor.

Beard’s widely publicized theory of neurasthenia served to medicalize nervousness as a somatic condition and associate it with the demographic most likely to seek professional intervention.  Ubiquitous advertisements for products such as Dr. Miles’ Nervine normalized and democratized nervousness as a condition from which anyone might regularly suffer as a response to everyday stress.  Neither camp had any empirical evidence to support their claims.  By 1904, the range of complaints attributable to neurasthenia had broadened to the point that some prominent neurologists called for its discontinuation in favor of more specific terms.  By the 1930s Beard’s notion of “nervous energy” and, correspondingly of “nervous exhaustion” had been discredited. (Schuster, p. 2328).

Nervine might not have cured all of the ailments it was claimed to treat, but its active ingredient was an effective, if potentially dangerous, sedative.  Discovered in the 1820s, several formulations of bromide (sodium, potassium, and ammonium, among them) were prescribed by doctors and widely sold in drug stores in the 19th century either on their own or as a component in an over-the-counter patent medicine.   So common was its use that it passed into the vernacular to mean a story, saying, or person so trite or boring as to put one to sleep.  Unfortunately, the line between effective and toxic was narrow and varied from person to person.  Overdosing could produce “bromide intoxication.”  In its mildest form the symptoms of bromide intoxication included fatigue, inability to concentrate, memory lapses, and sleep interruption.  More severe cases produced delirium, confusion, hallucinations, disorientation, tremulous hands, skin eruptions, and slurred speech.

In some ads Nervine was advertised as a sleep aid, as in this ad from the 1940s.  Note that by that time Nervine was available in several forms, including “Dr. Miles’ Effervescent Nervine Tablets.”  Miles Laboratories was also the maker of Alka Selzer, another effervescent tablet, which combined sodium bicarbonate and aspirin.  However, as the first ad shows, it was also intended to be use as what came to be called a “daytime sedative.”

When regulation of drugs and patent medicines occurred in the early 20th century, bromide continued to be dispensed by doctors as a prescription drug.  A 1936 article in the British Medical Journal (Nov. 14, 1936) entitled “Bromide Intoxication” cited a 1928 study that found that potassium bromide was one of the most commonly prescribed drugs in Great Britain and that one tenth of all prescribed drugs contained it as a principal ingredient.  Bromide was “the regular ‘diet’ of neurotics,” routinely prescribed with little regard for its ill effects.

The news of neurasthenia’s demise did not reach the office of Dr. Miles, however.   Miles Laboratories, as his company came to be called, continued to market bromide-based Nervine as a remedy for nerves, irritability, restlessness, sleeplessness, and “just an ‘off day’” until  1975, when an FDA advisory panel released its three-year study of over-the-counter “daytime sedatives,” finding that they were “worthless” and might actually cause harm because they “dulled the nerves.”  Nervine was singled out for particular criticism.  The panel was “especially distressed” to learn that bromides were still in use despite their toxicity being so well known.   With bromides being the only active ingredient in Nervine, the product would have to be totally reformulated if the recommendations of the panel were accepted by the FDA.  The panel recommended that drug manufacturers be given three years to “try to save their $7 million a year market.” (Raleigh News and Observer, Dec.  5, 1975, p. 16).