Railway Brain: The Body's Revenge Against Progress

Monsieur D. . ., age 45, a herbalist, was in the fourth car from the end of a train stopped in the Charenton station on 5 September 1881, when an express train rammed into it at full speed. He felt a violent jolt but suffered only a few bruises, the medical report noted.

D. . . helped other victims and then took the tram home. Shortly after, his behavior changed, and he began to experience severe and incapacitating physical problems. Before the accident, he was "an intelligent, skillful businessman," "affectionate and devoted to his wife and daughters," the report continued. A man of regular habits, never a drinker, with no serious illnesses or signs of "troublesome hereditary difficulties," Monsieur D. . . "was not prone to any health problems." Yet, "at present," the examining doctor wrote, "the physical and mental decline of Monsieur D. . . has reached such a point that it is no longer possible to hope for improvement."[1] Just the day before, he concluded, D. . . seemed overexcited and peculiar. He left the house, returned, swallowed a dose of poison, then, impatient with its slowness, "seized a knife and after stabbing himself seven times in the chest, died instantly."[2]

Not all such cases lasted so long or ended so dramatically, but the fact that people walked away from accidents uninjured and only later reported devastating symptoms perplexed doctors. Charles-Albert Vibert, a medical legal expert at the Paris Faculty of Medicine, examined eighty-six victims of the Charenton collision in the eight to ten days following the accident. Most of them complained of nightmares and headaches; they trembled and felt tremendous anxiety, but symptoms such as these usually disappeared in a few weeks, he observed.[3] Other accident victims returned right away to work as if nothing had happened and then after a few days, weeks, or months experienced increasingly serious physical and mental problems. They felt "violent pains in the bruised areas, in the head, in the spine," slept badly, and moved around with difficulty, observed Albert Blum, doctor at the Saint-Antoine hospital in Paris. "The patients become taciturn and they want to be alone," he continued. "They can't. . . leave their bed or their chair, they are obsessed with dark thoughts which can even include suicide. An indifference to everything around them. . .takes over."[4]

How to classify a condition characterized by multiple debilitating symptoms, which affected slightly injured and generally healthy accident victims? How to explain that only some of the people who walked away experienced these negative aftereffects? The issues raised, and the theories developed to deal with them, expose the medical logic of doctors at the end of the nineteenth and beginning of the twentieth centuries. They confronted striking evidence of a disease with no discernible physical roots and a seemingly random set of victims obsessed by their own physical and mental decline. Doctors accustomed to tracing pathologies to organic problems found this disorder baffling. Conventional wisdom suggested either that it existed in the patients' imaginations or that it stemmed from real but undetectable physical damage. New studies, however, challenged these explanations and pointed instead to functional disturbances of the nervous system.

Seen this way, the syndrome bore remarkable resemblance to neurasthenia, a disorder equally elusive in its origins and apparently equally indiscriminate in its victims. The pairing of the two conditions provoked a reconsideration of the causes of each one of them. Admitting that accidents could produce neurasthenia meant that one of the most debilitating illnesses of the day could strike any one at any time. On the other hand, if nervous diseases only struck weakened nervous systems, then people with railway brain harbored hidden hereditary defects. Coupling railway brain and neurasthenia brought the relative weight of accident and biological determinism to the center of the medical discussion. Exactly the same issue consumed social thinkers as they tried to determine the causes of deviant behaviors.

Railway brain

A number of highly publicized railroad disasters and the rise in damage claims against the companies from people reporting serious ailments but exhibiting no physical injuries attracted medical and public attention. A good deal of the litigation after railway accidents involved railway brain or "nervous shock," and no wonder, commented doctors.[5] The appeal of a life of "sweet nonchalance" tempted even solidly moral souls. In a case reported by Blum, the court awarded "G" 10,000 francs in damages and an annual income of 2,500 francs. Shortly after the verdict, Blum wryly noted, "as a result of metallic therapy, the paralysis, the visual problems, the memory loss, the mental softening disappeared as if by magic. . . . 'G' enjoyed good health and at the writing was 80 years old."[6] Judging from the attention doctors paid to dissimulation, they suspected that all victims of railway brain feigned or at least exaggerated their condition.

Called as expert witnesses to validate the claims, doctors needed some means of separating fact from fake. Tests designed to get at the internal roots of the visible symptoms commonly indicated nothing amiss. The patients reported headaches and gastric problems; they displayed motor and sensory difficulties, but nothing seemed wrong underneath. "[I]t must be abundantly obvious," complained a British expert on the subject, "how largely the reality of many of the symptoms, lacking all vestige of objective sign, depends upon the veracity and good faith of the patients themselves."[7]

Despite these doubts, the medical-legal discussions of railway brain insisted that patients genuinely suffered from the condition. The disease itself fostered a tendency to exaggerate, authorities asserted, so what led to suspicion of deceit in fact also confirmed the disease. Rapid recovery after a favorable settlement did not always indicate a shammer either, since relief from anxiety eliminated the symptoms in some cases. Moreover, experts reassured their colleagues that no one could simulate all aspects of the disease. With frequent, attentive examinations, the informed doctor could expect to unmask the malingerers.[8]

Identifying the real cases, however, depended on thoroughly understanding the sources and the symptoms of the disorder. Early medical experts theorized that railroad collisions shook the brain, creating lesions whose slowly-developing effects disabled victims. Vibert, for one, attributed the complaints of the eighty-six victims he studied to disturbances of their brains. An abrupt movement - too light to cause a bruise or a lesion on the brain - still produced a shock sufficient to provoke the headaches, insomnia, memory loss, and character changes he observed in these patients.[9] In most cases, he concluded, physical trauma so slight as to pass unnoticed produced inflammation which triggered the gradual onset of numerous and drastic complaints. The complex of symptoms he frequently saw looked strikingly similar, Vibert noted, to those described by John Eric Erichsen in his influential study of the effects of accidents published in 1866. Erichsen asserted that accidents shook the spinal cord, causing an infection which disrupted the operation of the nervous system. By this theory, the impact did not cause rupture or fracture, but it resonated through the spinal membrane, as it must have through brain tissue, launching pathological changes that "doomed the sufferer to a life of pain, misery and uselessness."[10]

In 1883 Herbert W. Page, doctor for the London and North Western Railway Company, dismantled this by then authoritative approach. He dismissed the idea of spinal concussion, arguing that the spinal column effectively protected the spinal cord against vibrations.[11] Imperceptible physical injuries evident in autopsies could explain why back pain developed, Page admitted, but most often muscle and ligament strain, what he called "traumatic lumbago," accounted for it.[12] To explain the delayed onset of multiple, debilitating complaints in healthy, uninjured accident victims, doctors needed to look elsewhere than the brain or spine, he asserted. Page himself attributed these more serious cases to "general nervous shock," a condition quite unlike the well-known state of emotional collapse that often immediately followed an accident.[13] "Purely mental causes"[14] such as fear or sharp emotion could, Page argued, trigger an aggravated and prolonged disturbance of the nervous system characterized by insomnia, vascular-motor troubles, headache, nervousness, trembling, despair, excessive sweating, visual problems, and the inability to concentrate.[15]

By 1889, remarked Salpêtrière intern A. Dutil, everyone understood "railway brain" as a functional disorder that affected not just the spine and brain but the whole nervous system. German doctors argued that it constituted a distinct illness that they called traumatic neurosis.[16] French doctors, like their Italian counterparts, saw striking parallels with the symptoms of neurasthenia and classified it as a form of that illness, or they accepted Salpêtrière neurologist Jean-Martin Charcot's diagnosis of a combination of neurasthenia followed by hysteria, a condition he labeled hystéro-neurasthénie.[17] Seeing railway brain as a type of neurasthenia affected how doctors imagined and treated it, but the linking of the two illnesses prompted an even more extensive and controversial reevaluation of neurasthenia itself by raising questions about who got it and why.

Neurasthenia

In a work published in 1888 the American doctor George Miller Beard described a new illness caused by the competitiveness and intensity of civilized life and characterized by exhaustion of the nervous system. This work attracted attention in the United States and in Europe where other doctors recognized the symptoms he catalogued. Most Europeans insisted that neurasthenia was not unique to the United States or even, for that matter, to the modern period. It was, French doctors concurred, a disease "as old as the world, or at least as medicine," but one on the rise in contemporary society, especially in cities.[18] One fourth of the patients at Salpêtrière, estimated a doctor there, suffered from neurasthenia.[19] Its prevalence made it, announced Dr. J. H. Bourguignon, the "illness of the day" (maladie du jour).[20]

If Beard was the father of neurasthenia, Charcot was for French doctors its godfather, credited with sharpening the nosological profile by identifying what he called its stigmata.[21] The way he narrowed the wide range of symptoms became standard among doctors. Doctors agreed that neurasthenics felt heaviness in their heads, or a sense of constriction, as if a tight helmet pressed in on them, doctors agreed. Similar sensations of pressure or burning occurred along the spine or in the lower back. Neurasthenics commonly suffered from insomnia, struggling to fall asleep then waking with a start in the middle of the night. They felt immense lassitude, an inability to move their bodies. Sluggish digestion also plagued victims. In addition they experienced disconcerting mental and emotional changes. Their minds strayed and they forgot things easily; they grew irritable, cried easily, and turned morose.[22]

A bevy of secondary symptoms, including impaired sexual performance, circulatory and respiratory difficulties, dizziness, and motor disturbances often complicated the disorder. The symptoms disrupted normal routines, causing neurasthenics to worry about their health and, imagining the worst, to organize their lives around the disease. Their preoccupations in some cases turned into pathological fixations, making neurasthenia a frequent harbinger of obsessive disorders and insanity.[23] The condition could also lead to drug addiction and suicide and to other illnesses brought on by enforced sedentary living or immense anxiety.[24] Even in the most serious or long term cases, however, the disease did not itself kill the patient, nor did it completely destroy their ability to think and act.

In the view of a number of French doctors, the same signs appeared in accident victims often enough to confirm a diagnosis of neurasthenia. Joseph Fabre, for example, recorded the case of a thirty-one year old male, victim of the collision of two trains: "Symptoms - headaches, dizziness, pains in the trunk, melancholy, insomnia, hyper excitability. Emotional. Weakening of mental acuity and memory; trouble urinating; sensitivity to the touch in the lumbar region. Trouble walking, especially on the right side. Numbness and problems with the sense organs on that side." The problems persisted, he observed, "notwithstanding a sizeable indemnity."[25] In another case, Claw. . . Louis, forty-two, an employee of the Compagnie International des Wagons-Lits, escaped with scratches and bruises when his train derailed and an express train rammed into it at full speed. He worked the next day at the accident site and then returned to Paris. Feeling shaky and emotional, he took to his bed for ten days but experienced horrible nightmares, then headaches, indigestion, and lower back pain. He went back to work but developed memory problems, trembling in the hands, and weakness in the extremities. Unable to continue, he took a leave, but the symptoms worsened and he became anxious and morose. Two months after the accident, in the first of a long series of "nervous attacks," he lost consciousness and fell to the floor, trembling all over and crying out. His case, concluded Dutil, indicated neurasthenia followed by hysteria.[26]

The functional disturbances associated with neurasthenia resulted, doctors agreed, from a single source: the exhaustion of the nervous system. The main culprit, overexertion, depleted people's reserves of nervous energy and provoked neurasthenia. To succeed in an ever more complicated world required doing more, getting more, knowing more, feeling more, and the incessant effort overloaded the nervous system. School children, forced to fill their minds without respite, easily succumbed to "scholastic neurasthenia."[27] Adults, too, could trigger neurasthenia by overworking their brains or by abusing leisure with a frenetic search for pleasure. Worry, disappointed love, failure at work - any emotional surcharge - could also sap energy and cause the system to flag. But neurasthenia struck people who managed their ordinary routines without difficulty as well. Fighting an illness could wear down the nerves and bring on neurasthenia and so, doctors asserted, could the physical shock or the emotional trauma of accidents, especially railroad collisions or serious falls.[28]

Lots of people in modern society worked or played too hard or worried too much, and according to one doctor, most of them experienced symptoms of neurasthenia. "There is no one, among those who are engaged in mental work," asserted Albert Mathieu, "who has not at certain moments experienced some transitory neurasthenic phenomenon."[29] The same thing held for someone who spent the evening "drinking and smoking. The next morning, there's a general achiness, headache, lack of appetite; work is impossible or at least very difficult."[30] Still, by no means everyone suffered the full fury of the disease. Its indiscriminate nature seemed especially clear in cases of railway brain. People could walk away unscathed from a collision or, for that matter, from a bad fall yet end up seriously incapacitated, while others never suffered any nervous impairment.

Just how shock, overexertion, sharp emotion, illness, or injury vitiated the nervous system mystified observers. Doctors found no evidence of structural damage in neurasthenia, but that did not mean, some asserted, that it did not exist, particularly at the level of the neurons and cells. "There are actually no psychic, sensory or moral phenomena without corresponding organic phenomena," intoned Levillain.[31] Others accepted that nothing changed organically; the nervous system just slowed down. Neurasthenia, by this view, took the form of a kind of "pathological fatigue"[32] or a "dynamic lesion of the cerebral-spinal system."[33]

Redefining neurasthenia

Lumping railway brain with neurasthenia exposed the ambiguity of an illness based on a deficit not a defect, one whose real symptoms co-existed with imagined illnesses. Including railway and other accidents among the causes of neurasthenia underscored the role of circumstances in producing this and possibly other nervous diseases. At the same time, it clearly demonstrated that people reacted very differently to apparently similar conditions. Some, not all, healthy, unscathed crash survivors and some, not all, hard working citizens succumbed to neurasthenia. Why them and not the others? Either they actually encountered more severe conditions, or their bodies harbored an undetected proclivity to nervous exhaustion, brought to the fore by the accident, by overexertion, or by an illness. A few doctors insisted that of all types of neurosis, neurasthenia was the only one which could occur completely by accident, without any hereditary predisposition to nervous problems. "Individuals born absolutely healthy, with no evident nervous defect, can become neurasthenics by accident as a result of nervous overexertion or from other causes," explained Levillain.[34] This was especially evident in railway brain. In the cases he reviewed, observed Albert Blum, "I rarely noted the existence of personal or hereditary antecedents."[35] Other doctors, however, believed that heredity always played some role, either by making people vulnerable to the disease or by giving it a special, more serious character once they got it.[36]

Still other medical experts admitted the importance of both accident and heredity, but they insisted that these two different sources produced distinct variants of neurasthenia: "true" neurasthenia and a "radically different" look alike.[37] The "radically different" type resulted primarily from heredity. This form belonged to a group of mental, nervous, and physical disorders that moved between generations. "The neurasthenic can be the son of a diabetic, or an eccentric, or an imbalanced or an insane person, to give some concrete examples," explained Albert Mathieu.[38] It constituted one of several associated degenerative diseases whose victims included hysterics, epileptics, hypochondriacs, the insane, idiots, imbeciles, and the sterile.[39]

"Hereditary" or "constitutional" neurasthenia, as they labeled this type, looked very much like "true," "classic," or "simple" neurasthenia "since the brain has limited means at its disposal to express its suffering."[40] But doctors confused the two at their peril, according to this group of doctors. "True" neurasthenia depended primarily on circumstances, such as a shock or overexertion, even when a background of nervousness predisposed the victim. It usually "affected people perfectly healthy in body and mind, who become neurasthenics in certain conditions." Proper treatment improved or cured the patient in the long term.[41] In hereditary neurasthenia, on the other hand, conditions played the secondary role and it "lasted as long as the patients themselves."[42] Moreover, hereditary neurasthenia produced much more drastic symptoms: "[victims] lead a miserable existence, always suffering, always obsessed with their disease."[43] They often developed phobias and obsessive disorders which required their permanent confinement in asylums.

Social parallels

The distinction between "true" and "hereditary" neurasthenia bore striking resemblance to the way social thinkers and criminal anthropologists understood social marginality in fin de siècle France. They insisted that poverty produced most crime and that unemployment explained most vagrancy. In these cases, as with neurasthenia, the challenges of modern life put normal people on the margins, usually temporarily. But they also identified another group of grand criminals and inveterate vagrants whose unfortunate heredity determined their anti-social behavior. In these cases, inborn defects corroded the will, destroyed moral sensibility, and damaged reason, leaving victims prey to primitive impulses and instincts.

The logic that caused experts on social marginality to distinguish between accidental and hereditary deviance is arguably the same that doctors used when they separated true from constitutional neurasthenia. Attributing spectacular crime and the inability to settle down to biology meant that inherited anatomical defects forced a sad, selected few into dangerous deviance. As a result, ordinary people of normal, solid stock could look at these deviants from the other side of a divide defined by biological fatality. Similarly, identifying a group of people born with defective nervous systems explained away the most serious cases of neurasthenia and let the "true" neurasthenics take their medicine, get a rest, and return to the maelstrom. The fact that most crime, vagrancy, and nervous exhaustion - everywhere on the rise - resulted from circumstances rather than from organic anomalies made these disturbing phenomena less menacing and more manageable. Judicious social reforms and wise personal hygiene aimed at combating the worst effects of civilization promised to keep all but the truly defective in the mainstream. In the case of the genuinely impaired, confinement defended society and protected the future by taking them out of circulation.

The distinction between heredity and accident won support, but it also produced some back-pedaling. The experts found it easy to accept the role that heredity played in causing irregular behavior, but they had trouble admitting that modern life by itself could drive normal people to commit crimes, leave home, or fall apart. The discussion of railway brain demonstrated the reluctance of doctors to accept the idea that accident or circumstances alone triggered nervous collapse. They struggled with why some accident survivors or overactive citizens succumbed to neurasthenia and others did not, just as social experts wondered why poverty and unemployment drove some people but not others to crime. Possibly these temporary outcasts faced more drastic circumstances and responded to them as anyone would. In that case, everyone felt equally exposed if struck by an accident, an emotional trauma, a demanding job, or an economic downturn. Or the victims carried the germ of deviance or illness hidden inside, and the conditions brought it to life. In that case, even the apparently normal, healthy people harbored a moral or physical weakness, likely inherited, likely unsuspected. Already abnormal, they could not actually have responded otherwise to the situations they faced. Recognizing the role of heredity even in "true" neurasthenia, as many doctors did, collapsed the distance between the "innocent" and the "doomed" victims of the disease. But it simultaneously expanded the gap between those protected against nervous collapse by sound heredity and those exposed to it by their inherently defective nervous systems.

The distinction between "true" and "hereditary" neurasthenia also broke down for some experts when it came to the consequences of the disease. What came by chance never left, since true neurasthenia, in their view, turned into the hereditary form of the disease.[44] Whatever caused it, all neurasthenics, according to these analyses, carried neurasthenia in their blood and passed it to their children, either directly or, more commonly, in one of its many allied forms. Worse, it provided the original, fertile terrain for the development of all types of degeneracy.[45] "Neurasthenia," specified Levillain, "is evidently at the origin of a whole series of neuropathologies; it is the true mother of the whole neuropathic family!"[46] If at the moment of conception or during pregnancy, he continued, the parents suffered from neurasthenia, then "the descendants run the greatest risk of an inherited nervous defect" or of mental illness.[47] Thus, cautioned Mathieu, "the son of a neurasthenic can be an eccentric, a maniac, suffer from gout, epilepsy, migraines, or neurasthenia."[48] According to these dire predictions, neurasthenia promised over time to compromise the race. In the immediate, it adversely affected the individual, the family, and the wider community.

An indictment of progress

The accidental, social quotient of neurasthenia, so sharply demonstrated by railway brain, put progress on trial. So did the evident role that poverty and unemployment played in producing "occasional" criminality. In these cases, modern living wore down the resistance of healthy, energetic citizens to neurosis or of the well-intentioned to illegality. And it happened more and more frequently, as statistics, experts, and informal observation confirmed. Precisely those attributes that elevated moderns over primitives, according to widespread views at the time, proved destructive to individuals, society, and the race. The cellular complexity and the exquisite sensibility of the evolved body exaggerated the impact of every stimulus and wore down the nervous system. Moreover, the prized acquisitions of the highly evolved, will power and self-control, also ruined children and conscientious adults. Their capacity to work long hours exposed them to nervous collapse and its multiple mental and physical consequences.

The toll in illness also exposed an underside to bourgeois values. The drive to succeed pushed adults beyond their forces, and public education overburdened a generation of children. Leisure time, the reward for work and wealth, only increased the burden on the nervous system, as people turned the promise of happiness into a frenetic search for pleasure. Furthermore, the new ideas and inventions produced by progress increased the cacophony and confusion. "Caught up in the whirlwind of cities, obsessed by the example of others, he proceeds, the unfortunate, all his nervous cells in a state of continual over-activity, toward a goal he can't identify, because he will never be satisfied."[49] This problem, as French doctors saw it, applied in particular to the United States, but even in France, anyone embracing modern values and lifestyle and anyone willing to get on a train risked the body's revenge. Mathieu observed: "We do not need to say much more to show how life in society in our time leads to neurosis. We overexert ourselves to create a profession. We prepare and we take exams or competitions. We overexert ourselves to earn money. We overexert ourselves to make a name for ourselves, to eclipse our rivals. We overexert ourselves on the pretext of enjoying ourselves or relaxing."[50]

Neurasthenia struck innumerable people and frightened doctors into apocalyptic predictions about the future of the race, and then it largely disappeared, its symptoms subsumed into different disorders with different names. To see the syndrome at all, and to see it as doctors did, says as much about medical thinking at the time as about what people actually suffered. End-of-the-century doctors made a special place for neurasthenia in their taxonomy of mental disorders. And in France, they put railway brain in that rubric. The nature of the space and the disorders installed there reveals a logic quite similar to that used by social thinkers and criminologists to explain social ills. To the modern ear, railway brain and railway spine sound quaint and anachronistic; post-traumatic stress disorder better fits the contemporary assessment of the wages of fear. The broader category, neurasthenia, as doctors a century ago described it, now disappears into depression, chronic fatigue syndrome, or stress.[51] Arguably, though, the change in labels covers a similarity in understanding. These disorders, however named, involve a functional collapse brought on by modern life, a collapse characterized by serious physical, emotional, and mental symptoms. They confirm the vulnerability of apparently healthy people to the nastier effects of civilization.

1. Albert Blum, De l'hystéro-neurasthénie traumatique (Railway-Spine) (Paris: Asselin et Houzeau, 1893), 39. Blum took the case from [Charles-Albert] Vibert, Etude médico-légale sur les blessures produites par les accidents de chemin de fer (Paris: Librairie J.-B. Baillière et Fils, 1888), 71-77.

2. Blum, 40.

3. Vibert, 13 and Blum, 4-5.

4. Blum, 5-6. See also Vibert, 37; Herbert W. Page, Injuries of the Spine and Spinal Cord without Apparent Mechanical Lesion, and Nervous Shock in their Surgical and Medical-legal Aspects (London: J. & A. Churchill, 1883), 151-57. Cases of real, physical damage to the nervous system, he argued, occurred very rarely.

5. Blum, 94 and Fernand Levillain, La neurasthénie: maladie de Beard (Paris: A. Maloine, 1891), 320.

6. Blum, 15-16. For the "sweet nonchalance" reference, see 105. See also A[lbert] Mathieu, Neurasthénie (épuisement nerveux) (Paris: J. Rueff et Cie, Editeurs, 1892), 124. "C'est la métallothérapie, non par l'or, mais par le billet de banque!"

7. Page, 157.

8. See, for example, L[éon] Bouveret, La neurasthénie (épuisement nerveux) (Paris: J.-B. Baillière et fils, 1890), 147-48.

9. Vibert, 34-38.

10. Page, 2-3. Erichsen, Page reported, published Six Lectures on Certain Obscure Injuries of the Nervous System Commonly Met with as the Result of Shocks to the Body Received in Collisions on Railways in 1866 and then another work, Concussion of the Spine, Nervous Shock, and Other Obscure Injuries, published in second edition in 1882; Vibert refers to Erichsen's On Railway and Other Injuries of the Nervous System, published in London in 1866.

11. Page, 28ff.

12. Ibid., 106.

13. Ibid., 143-44.

14. Ibid., 167.

15. Ibid., 158-66.

16. A. Dutil, Hystérie et neurasthénie associées (Railway-Spine et Névrose traumatique) (Paris: Librairie Octave Doin, 1889), 8. See also Joseph Fabre, De l'hystéro-neurasthénie devant la loi dans les accidents de chemin de fer (Paris: Henri Jouve, 1893), and Blum, 2.

17. Jean-Martin Charcot, Leçons du mardi à la Salpêtrière, professeur Charcot. Policlinique, 1887-1888, Vol. 1, 2nd ed. (Paris: Babé, 1892), 4th Lesson, Tuesday, 13 Dec. 1887, 52-54. He saw a sequential connection, neurasthenia followed by hysteria, but others saw it as a mixture of the symptoms of both. See also Dutil, 8.

18. Levillain, 1; Mathieu, 7-8; Emile Laurent, La neurasthénie et son traitement, 2nd ed. (Paris: A. Maloine, 1897), 2-3. Dr. [Lucien] Angelvin, La neurasthénie, mal social (Paris: Edouard Cornély, 1905), 19, agreed with Beard that it was a new disease.

19. Levillain, 13; Paul Blocq, La neurasthénie et les neurasthéniques (Paris: Imprimerie F. Levé, 1891), said one-twelfth of the people who came to Salpêtrière for external consultations had it, a figure he believed underestimated the incidence of the disease, because it usually struck people of the upper class more while those who visited the hospital were not of the upper classes, 7-8. For a discussion of Charcot's general views of traumatic neuroses, see Mark S. Micale "Jean-Martin Charcot and les névroses traumatiques: From Medicine to Culture in French Trauma Theory of the Late Nineteenth Century," in Traumatic Pasts: History, Psychiatry, and Trauma in the Modern Age, 1870-1930, eds. Mark S. Micale and Paul Lerner (New York: Cambridge University Press, 2001), 115-39.

20. J. H. Bourguignon, La neurasthénie: ses causes, ses symptomes, son traitement, 4th ed. (Paris: Laboratoire Bourguignon, 1911), 3.

21. Levillain on Charcot as "parrain," 13.

22. Ibid., 76-108; Blocq, 11-13; Laurent, 12-22; Georges Martin, Etude sur la neurasthénie et l'état mental des neurasthéniques (Paris: A. Maloine, Editeur, 1898), 8, for example. The treatises all described the symptoms and in very similar ways.

23. Martin, 57, argued strongly for the existence of "neurasthenic folly" as part of the disease itself.

24. Blocq, 26.

25. Fabre, 108-9.

26. Dutil, 9-15. The accident occurred on the night of 4-5 Sept. 1888, and the patient entered Salpêtrière 3 July 1889.

27. Charcot took issue with this frequently cited problem, arguing that children lacked the will power to overwork, 15-17.

28. See Levillain, 36. See also Bouveret, 11-30, for a detailed discussion of the etiology of neurasthenia.

29. Mathieu, 16.

30. Ibid., 16. See also Angelvin, 8.

31. Levillain, 161.

32. Ibid., 14-15.

33. Martin, 7. Doctors such as Fulgence Raymond, Neurasthénie-syndrome (neurasthénie simple, acquise ou accidentelle), leçon faite à l'hospice de la Salpêtrière (Paris: Imprimerie Typographique Jean Gainche, 1907), 3, insisted that in this case neurasthenia was not a disease, but a syndrome or "state" announced by a set of clinical signs. See also [Georges] Gilles de la Tourette, Les états neurasthéniques: formes cliniques, diagnostic, traitement, 2nd ed. (Paris: Librairie J.-B. Ballière et fils, 1900), 3.

34. Levillain, 18. He admitted he could accept that even these people had a pathological inability to recover from strain or exhaustion, 18-19. Martin, 11, said one could "often" see neurasthenia develop without any hereditary link.

35. Blum, 96.

36. Laurent, 4-5.

37. Gilles de la Tourette, 38.

38. Mathieu, 162.

39. Ibid., 176; Auguste Vial, Dégénérescence mentale et neurasthénie (Lyon: A. H. Storck, 1897) set out to prove that neurasthenia was the "well spring of all degenerative states."

40. Gilles de la Tourette, 36. See also Bourguignon, 3-4. He and Fulgence Raymond preferred to call "hereditary neurasthenia" "psychasthénie."

41. Raymond, 10.

42. Bouveret, 141. See also Gilles de la Tourette, 37-38 and Raymond, 6.

43. Gilles de la Tourette, 46.

44. Social thinkers warned that occasional criminals risked turning into habitual offenders or that social conditions risked producing a class of criminals who looked and acted alike. See, for example, Gabriel Tarde, La criminalité comparée, 7th ed. (Paris: Félix Alcan, 1910), 21-23 for the criminal look and 82-83 for imitation.

45. Vial, 25.

46. Levillain, 201. He specified that "to be a mother, you have to have the age and the means: it is ordinarily necessary then that neurasthenia is very pronounced or old enough in the individual or the family to produce a hereditary strain."

47. Ibid., 37-38.

48. Mathieu, 183.

49. Angelvin, 35.

50. Mathieu, 21.

51. Mark S. Micale, "On the 'Disappearance' of Hysteria: A Study in the Clinical Deconstruction of a Diagnosis," Isis 84 (Sept. 1993): 496-526 argues that changes in diagnosis and in classification schemes caused hysteria to "disappear." His analysis applies equally well to neurasthenia.