Exhaustion

Exhaustion: A History by Anna Katharina Schaffner is a vigorous review of the various lenses through which exhaustion has been viewed throughout human history. Throughout this review, Schaffner is making the case that exhaustion, though treated as something new by each successive generation, is better understood as the same snake shedding different types of skin. She suggests that although exhaustion is considered a more modern phenomenon, it has actually manifested under various guises over the centuries. Schaffner poses the following questions regarding exhaustion and the specter with which it shadows humanity:“Is not ours the most exhausted age in history? And does the current epidemic of exhaustion not threaten the very future of the human animal? There are many who believe this to be the case. Yet before simply assenting to this assessment of our times, there is another question that needs to be asked: What do we really mean when we speak of exhaustion?” (4)Schaffner offers the following persuasive answers: ours is not the most exhausted age, just the latest one to think it is; and exhaustion defies a specific definition but there is a recognizable phenomenon that recurs across history—a feeling of deep depletion, of having used up all of one's energy. Exhaustion is a slippery concept that defies a specific definition but speaks much more to the cultural mores and overlying themes that continue to shape history at various points. As opposed to other discussions of exhaustion, for example, such as Galen's On the Affected Parts, which are limited in their temporal scope, Schaffner's is valuable precisely because of its historical sweep.In her introduction, Schaffner lays out her key assumption, which she then substantiates even as she explores its consequences: “exhaustion can be understood not only as an individual ... state but also as a broader cultural phenomenon” (5). She also elaborates on what this term encompasses for her, noting that it can apply to physical, mental, or spiritual states and that it has a temporal dimension—it can be brief, intermittent, long lasting, or permanent (5).In making the case for this view of exhaustion, she relies on the following strategies of analysis: etymology, rooting her observations in reverberations seen in historical primary texts specific to each epoch, and numerous references to works of literature.Schaffner separates the chapters into sections based on the predominant school of thought governing exhaustion theory during specific periods. Chapter titles include “Humors,” “Sin,” “Saturn,” “Sexuality,” “Nerves,” “Capitalism,” “Rest,” “The Death Drive,” “Depression,” “Mystery Viruses,” and “Burnout” and they serve as touchstones from which these different theories spring. Her subject matter ranges from Galen's writings dating back to fifth century BCE. to the more recent work of Naomi Klein.Schaffner's background in linguistics shines throughout the text as she makes clever use of word origins and definitions, which pave the path for the introductions of new concepts and theories. In “Sin” she notes the term acedia is “derived from the ancient Greek word for indifference, listlessness, or apathy... [l]iterally, it denotes a ‘state of noncaring’ (specifically about divine matters) and has been described as ‘weariness of the heart’” (32). In this same section, she provides an impressive back and forth between the Italian and English translations of Dante's Inferno, underscoring the importance of etymology in its application to literary texts and her theories (44–51). In “Burnout,” she traces the origin of the term to “the 1970s in the United States as a popular metaphor for mental exhaustion among social sector workers” (213).Within each section, she also traces the reverberations of the dominant concept beyond its own cultural heyday. For example, in “Humors” she references the current and widely accepted theory of depression as a source of neurochemical imbalance, then reaches further back to tie this concept of imbalance of specific substances in the body to the ancient humoral theory (15). Also in “Humors,” she extensively analyzes the primary text of Galen's humoral theory. In “Sin,” she references the works of mystic scholar Hugh St. Vincent. “Nerves” provides an overview of an eighteenth-century treatise by a Scottish physician aptly titled The English Malady. Also in “Nerves,” she shares of Oscar Wilde's mockery of the all-encompassing nature of his diagnosis of neurasthenia “[m]y doctor says I have all the symptoms. It is comforting to have them all, it makes one a perfect type” (91). In “Sexuality” she references Karl Marx's Capital, in which he writes “[c]apital is dead labor, which, vampire-like, lives only by sucking living labor, and lives the more, the more labor it sucks” (80). In “The Death Drive,” she employs Freud's treatise, stating that he “presents his second big theory on the mechanisms of human energy exhaustion in his groundbreaking essay ‘Beyond the Pleasure Principle’”(155). In “Rest” she discusses treatment of Charlotte Perkins Gilman by Silas Mitchell—who developed the rest cure—and how this manifested in her most famous short story, “The Yellow Wallpaper.” In “Rest,” Schaffner suggests that Mitchell's treatment of women with nervous exhaustion “illustrates once again how cultural critique and medical diagnosis can be fused together, often in insidious ways ... [and] are used as vehicles to express fears about social transformation” (142).Schaffner skillfully interweaves an impressive array of literary texts into her larger argument. Her discussion of nervous exhaustion in “Nerves” begins with a character sketch of the Edgar Allan Poe's Roderick Usher, “a product of cross-generational inbreeding and a thinly veiled parody of the high-strung Romantic artist” (85). In “Saturn,” Schaffner employs an analysis of Hamlet in order to illustrate the shift to a “self-reflective, self-aware subject,” and is quick to point out that Hamlet “can be interpreted as a representation of the acedic and melancholic type, and his story as a cautionary tale about the adverse effects of introspection” (57). She shares Walter Benjamin's observation that “[t]he indecisiveness of the prince, in particular, is nothing other than saturnine acedia...Saturn causes people to be ‘apathetic, indecisive, slow’” (57).In “Sexuality” she remarks upon Stoker's Count Dracula and other vampires as “recurrently associated with capitalist exploitation, they quite literally suck their victim dry, parasitically draining their life energy and ruthlessly depleting their resources for their own precarious survival” (80). In her “Burnout” chapter, she discusses Graham Greene's novel A Burnt-Out Case—a rather prescient novel, as she notes it was published ~ 14 years before the clinical diagnosis of burnout was born (223). She notes that Querry, the “celebrated ecclesiastical architect,” experiences burnout's core symptoms, including “feel[ing] as though he has come ‘to the end of everything’” (223). She selects several noteworthy sections from this novel, including Querry's observation, which speaks directly to what may be seen as a definition of burnout: “A vocation is an act of love: it is not a professional career. When desire is dead one cannot continue to make love. I've come to the end of the desire and the end of my vocation” (224).Utilizing the above strategies of etymology and citing relevant literary representation, Schaffner manages to create a sweeping review of exhaustion throughout human history. Several concepts conveyed in this history spoke to me as a clinician. In “Depression,” she shares a very personal and extremely insightful case study provided by her grandfather, who experienced a paralyzing depression following the five years he spent as a prisoner of Russia following the World War II (169–170). Perhaps the most summative metaphor of depression, which I have encountered, she shares the following exchange between her grandfather and the town doctor:“You have two choices, young man: either you pull yourself together, get up and be a good husband to your wife, or else you should do us all a favor and die.”My grandfather sighed and responded: “I'd very much like to. But I'm just too tired to die” (169–170).I found some of Schaffner's discussion of patients with chronic fatigue syndrome (now more commonly referred to as Systemic Exertional Intolerance Disease or SEID) to be especially resonant. She observes that patients with SEID soundly reject the hypothesis that SEID does not indeed have an organic etiology (i.e., a virus, autoimmune response, or hormonal deficiency or excess) at its root. She notes that “[m]ost patient pressure groups embrace fiercely anti-psychiatric rhetoric and sometime attack and insult psychiatrically oriented researchers who, they feel, call into question the reality and severity of their suffering by suggesting ‘it is all in their head’” (191). Indeed, she observes that many persons who suffer from SEID feel that any anxiety or depression that they experience is a secondary, reactive response to the chronic and often debilitating disease. Schaffner shares the patients' view that psychiatry typically oversimplifies their condition, even as she treats the patients' self-diagnoses with a compassionate skepticism. Schaffner refers to Scottish SEID blogger Nasim Jafry who alleges that there is a conspiracy among scientists working on the disease. They are, Jafry writes, willing to “do anything to prevent biomedical research into ME [myalgic encephalomyelitis] [because] they desperately want to keep it all to themselves....it truly beggars belief that an individual doctor can seek – with catastrophic results – to overturn the reality of so many patients, and the reality of other doctors and researchers” (192).I find myself siding with Schaffner and Jafry—and my patients, even as I find myself wishing I could do more for them. I acknowledge that we do not grasp the cause—the “why” of SEID—but attempt to instead focus on moving forward. Many of my patients of whom I suspect have SEID are constantly searching for new tests to find an all-encompassing diagnosis to explain their symptoms and will pay hundreds, maybe thousands of dollars out of pocket desperately searching for a diagnostic test or cure that neatly fits into the ICD-10 diagnostic schema. One patient uses all of her financial resources to buy vitamins and supplements in the hopes of experiencing more energy and less pain. Another patient travels out of state to receive several months of IV antibiotics in the hopes of improving his symptoms. I am reminded of Laura Hillenbrand's1 essay “A Sudden Illness,” in which she details her years-long struggle with chronic fatigue syndrome and chronic vertigo, as a way of understanding and a very moving portrayal of living with this disease (witness her various transitions: for seven months and in two years). Indeed, I think it would fit both with Schaffner's method of finding relevant literary representations and with her particular stance on the gap between SEI and its treatment. I shared this essay with the latter patient, who acknowledged the similarity with his story with tears in his eyes, only to tragically ask moments later “did she ever get any better?”Another particularly salient observation occurs near the end of her “Mystery Viruses” section, where Schaffner observes:“The debate over the biological or psychogenic origins of CFS may sound academic even obscure. However, the ways in which we imagine and represent our illnesses, the narratives we tell ourselves and others about them, and the etiological theories in which we believe do matter. Beliefs, internal representations, and metaphors affect how symptoms are experienced, how we cope with them and how we interpret bodily signals. Such beliefs can, of course, also be damaging or self-perpetuating; for example, the assumption that one's condition is incurable and possibly even fatal, and that rest is the only way to manage one's symptoms, can become the cause of anxiety and depression and perpetuate behavior that may aggravate or complicate the development of an illness.” (199)I consider the above excerpt as a reason for which narrative medicine has assumed critical importance in today's complicated, biopsychosocial model of health care.I close by noting that Schaffner herself presents her study as a tale of two popes. In the introduction, Schaffner describes Pope Benedict XVI's announcement of his retirement on February 11, 2013. So moving did I find her introductory paragraph that I would like to share an excerpt:“On a wintry afternoon in February, an old man steps out onto a balcony. There are no clouds in the sky, but a chilly wind is blowing. The old man shivers and wraps his garments more tightly around his frail, delicate body. His hair is as white as his robes. His face is a landscape marked by toil and sorrow, and the dark shadows under his watery eyes are an unhealthy shade purple. His head is bowed so deeply it almost forms a right angle with his hunched back, and his hands are trembling. He tugs at the heavy gold ornament that hangs around his neck.... The figure is not just any old man. It is Pope Benedict XVI, who announced his retirement to an astonished world on February 11, 2013, in a statement composed in Latin.... He reported both physical and spiritual exhaustion and offered his advanced age and deteriorating physical strength as the primary reasons for his decision to retire.” (1)This excerpt stands in sharp contrast to the figure we see in the epilogue, a man who discusses the effects of climate change and the fallout from the depletion of natural resources, sharing that climate change scientist “received support from an unlikely ally.... In his encyclical aptly titled ‘On Care for our Common Home,’ Pope Francis I takes a candid and fierce stance against unfettered consumerism and climate change” (240–1). She elaborates how, in his treatise, Pope Francis, “in contrast to his exhausted predecessor Benedict XVI... presents concrete solutions to the problems he raises and appears hopeful that a better future is possible” (241). As a remedy to the travails experienced by Benedict, Francis “urges his flock to remember to honor the Sabbath, the law of weekly rest that exists to counter physical and spiritual exhaustion” (242)

History · History of Medicine Studies · Medical History and Innovations · Sleep and Work-Related Fatigue