Book Review: A History of Fatigue from the Middle Ages to the Present

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A History of Fatigue from the Middle Ages to the Present by Georges Vigarello (translated by Nancy Erber), Polity Press 2022.

A History of Fatigue Idon’t know about you, but “tired” seems to be the new fine. Maybe that’s because, for the last several years, “busy” used to be the new fine; I hear more statements about fatigue than I used to about being busy, which is alarming. It’s not just that we refuse to take naps when we’re young and then it seems like all we want to do as an adult is sleep (especially when we can’t). It’s that, as Georges Vigarello details in A History of Fatigue, our cultural context has a large say in when to be tired (“there was no burnout in the Middle Ages”), and who gets to be tired (the Middle Ages prioritized the warrior, the traveler and the pilgrim over the laborer). Fatigue is a material, spiritual and psychological reality, and studying its history is the study of being human. One hypothesis of this book is that the increasing idea of the autonomous “self” is directly proportional to how difficult it is to accept limits, vulnerabilities, obstacles and weaknesses, which ironically has led to a greater sense of fatigue.

Vigarello provides a massive history of how society has thought about fatigue since the Middle Ages, focusing for the most part on workers—and how consistently physically and mentally exhausted they’ve been throughout the ages—even as society up until the 1900s basically ignored workers. At first, I thought that was a limiting factor in the relevance of this book to mental health. After sitting with notes for a few days, I realized that the book’s focus on workers is not only not a hindrance but actually highlights something about our culture today: we are all workers. We may not have 9-5 jobs, but modern life requires extraordinary amounts of work to maintain despite the promises of technology of ease and convenience.

That might be because, as Vigarello points out, as technology has advanced, the conceptualization of fatigue has morphed from purely physical tiredness up until about the 20th century to mental exhaustion. Vigarello seems to understand the physical and the mental to be more separable than they actually are, though, so the distinction, while helpful, only goes so far. He does acknowledge that, starting in the 1950s, scientific studies started to intentionally study physical fatigue and mental exhaustion—which was the original definition of stress—as co-occurring phenomena that impact each other.

But it took a long time to get there. Fatigue in the Middle Ages meant a lack of matter—it arose from what had been lost, and its causes were mysterious. It was a phase rather than a condition to be investigated and treated. “The internal exhaustion had to be visible; it had to be manifest externally since it could not be explained in psychological terms.” Thus, remedies were physical: purging or bleeding themselves before traveling long distances to purify/dilute their humors (which seems to contradict the idea that lack of fluids was a cause of fatigue in the first place), consuming herbs and spices, eating only light meals and excluding fruits with excessively “raw” flesh, refraining from speaking to literally “save their breath,” and placing precious stones in one’s mouth, among other proposed prophylactics.

While emotions were believed to contribute to fatigue, they were considered too subjective to be scientifically explored; thus, the Middle Ages did not see much introspection and fatigue was a sign of atonement earned through rigor. This echoes our recent days of “busy is the new fine,” except that fatigue, it was believed in the olden days, often came from unrelenting self-sacrifice, or, at the very least, an uprooting from the self. This is nearly the opposite of our modern culture of bingeing on self-care and battle cries of putting ourselves first and far ahead of everyone else. Yet are we less fatigued than the self-denying people of the Middle Ages?

17th Century: Fitness for Labor and Battle

The understanding of fatigue diversified with the advent of modernity, broadening the range of exhaustion even as it fragmented it. Intellectual curiosity about fatigue grew, and with it, measurements, categories and degrees of it. In this modernizing world, men were the ones subject to scrutiny about their physical appearance for their suitableness for certain kinds of labor and/or on the battlefield. The effects of fatigue on the mind/mental processes started to be recognized for the first time, brought on by mental exertion. The symptoms were implied rather than specified, but they suggested a feeling of weakness and loss of mental acuity. This gave way to another definition of fatigue: being “tired of” something as in “fed up” with it, which is the first evidence of the recognition of a psychological aspect of fatigue. Interior experiences of fatigue were finally acknowledged, even if its actual mechanism was not described but began to result in equating physical and mental fatigue by the end of the 17th century.

As time and distance started to be more precisely measured for travelers and workers, disputes began to arise about how much work laborers were being asked to do as well. Although the belief that the main cause of fatigue was imbalance of the bodily humors remained, more specific explanations started to be developed and more attention started to be paid to subtle warning signs of fatigue even as methods of treatment remained similar to those in the Middle Ages. As humanity entered modernity, the image of the body remained the same but curiosity about it increased, tolerance about old ways decreased and diversity came to the understanding of fatigue.

Poverty did not start to be acknowledged as a source of fatigue until the late 17th century, which is not to say that the status of poor people was improving. Poverty was still believed to be endemic to climate and geography, intrinsic helplessness and other conditions outside of the social structures built by humans—the understanding of systemic oppression may have been called something different, but it’s been around a lot longer than our current age.

18th Century: the Age of Enlightenment

The 18th century brought more focus on feelings as well as rationality due to the Enlightenment, and thus a more personalized quest for affirmation, and a modern—that is, psychological—approach to overcoming fatigue in a way that did not involve religion. More sources of fatigue were recognized, thus, fatigue became more personalized and more of a force in literature and personal accounts, and less of a mere discomfort. Weakness was no longer a sign of humanity’s fallenness but a real human experience that started to drive people to pay attention to their own personal experiences.

Scientists began more closely examining fragility, but there was still no evidence that psychological distress played a role in fatigue. The concept of fatigue was becoming more personal, though, and people started paying more attention to their own experiences over and above what society dictated, setting the stage for the awareness of the psychological dimension of exhaustion. As this shift occurred in the last half of the 18th century, people with physical and mental disabilities, before now invisible, were less accepted maybe because the phrase “public health” made it into common parlance for the first time, suggesting that the state was responsible for the health and well-being of the populace rather than simply to control and govern. The medical field began to classify symptoms by their severity rather than their location in the body; physical symptoms were still primary in the understanding of fatigue, but they were different ones: the focus moved from loss of fluids to the flesh, the body itself and how it could lose or maintain its substance—scientists started to classify fatigue as a loss of muscular activity.

Late 18th Century: the Rise of Individualism

The increasingly focused study of fatigue became a study of human limits, which provoked a more detailed examination of labor, overlooked for so long and unrecognized as a social good and source of wealth. Concern with the lifespan grew throughout the century. The goal of Enlightenment thinkers, in a nutshell, was to increase and systematize efficiency while respecting the limits of the human body. The problem was that the focus was only on calculated mechanical limits; the wear and tear of various forms of labor on the body were neglected, emotions were still expected to be repressed. Workers in myriad fields began to revolt against the “soulless, mechanistic monotony” of their jobs, which changed the understanding of fatigue, at least in bosses’ minds, to an issue of reward rather than a sign of salvation. The rise of individualism shed light on individual experiences of fatigue, which gave rise to a new understanding of the human body and the desire for autonomy. Being conscious of one’s pain was now an affirmation of one’s existence.

Remedies switched from replenishing “humors” to firming up bodily fibers; electricity became a popular way to do so as were progressive exercises that built up stamina over time little by little, which may be a precursor to the use of ECT as an acceptable treatment for mental “disorders,” though Vigarello doesn’t make that connection explicitly. There was a marked increase in the emphasis on internal and experiential focus in the effectiveness of these new remedies as well as the idea of incremental progress. This set the stage for fatigue to take on a psychological dimension and the hope that human perfectibility was limitless if undertaken in small doses. What Vigarello doesn’t mention is that this has led to horrific ideas and practices throughout history that have especially victimized people deemed mentally and physically “disabled” by society.

19th Century: Increasing Productivity

The 19th century renewed the studies and categorizations of fatigue, emphasized the individual experience and measurements of its resources and “deficits.” Recognition of deprivation and despondency increased; research advocated for better working conditions and shorter work hours. Yet exhortations to “get stronger” and “make your own way in life” as well as more intense psychological gymnastics were developed to support people’s building of self-confidence. Much like our own times, it was a badge of honor to be fatigued because it showed you were participating in the collective well-being of society as well as trying to better your station in life, which was no longer seen as stationary, thus increasing the value of competitiveness. The understanding of fatigue, however, remained purely descriptive.

The increasing revitalization of society provoked by science and technology, with a near exclusive focus on numbers, encouraged a materialistic focus and efforts to “better humanity” focused on increasing productivity while minimizing their energy output, which meant getting used to interacting with machines. Fatigue was seen as a compliment to physical labor; everything was still very much “physical,” as opposed to mental, emotional or spiritual. The build” of an individual was scrutinized for the first time: the lungs were considered the first line of defense so a broad chest and strong (rather than sunken) collarbones were signs of being able to better work under adverse conditions.

The Industrial Revolution made poverty and its attending miseries impossible to continue to invisibilize; the conditions of the working poor were at stark odds with the prevailing narrative of increasing and inevitable progress. This led to a new interest among the public and the media in social issues. At the start of the 19th century, social classes tended to be more heterogeneous and broad, so “the poor” were a more mixed class than the cultural understanding of “the poor” in those days indicated. Still, poverty had become so common that someone working 18 hours a day could not afford the basic necessities. Thus, fatigue was seen as necessary and manual labor synonymous with strength. Despite constant workers’ protests, true labor reform would not happen until the end of the 19th century.

Late 19th Century: the Emergence of ‘Mental Fatigue’

The “laws of exhaustion” suggested by an inventor of a fatigue-measuring device included one that seems obvious to us now: feeling pain coincides with a notable decrease in exertion and work breaks delay the onset of exhaustion. Of course, this catalyzed a series of fatigue experiments where the tired person became the guinea pig for the sake of advancing the scientific understanding of fatigue. A psychological component of fatigue crept into the public understanding on a conveyor belt: the Ford assembly line reduced the production of a motor vehicle from over 9 hours to just around 6 in six months; yet turnover was high due to worker complaints that they were losing the ability to think for themselves. Mental health occupied a large space in the culture at the turn of the 20th century, but it had not reached the world of work. A “psychologization” was underway; yet “mental fatigue” still had its own boundaries.

Yet the growing focus of individual experience was giving way to a two-pronged understanding of fatigue: the classic physical one and the mental/internal one; this change from giving circumstances less attention than feelings when considering fatigue was a huge shift in perspective. Fatigue was inevitable in a society obsessed with self-improvement and competition. Literature started to include mental/emotional conceptions of exhaustion, and the idea that fatigue could be caused by too much newness too soon as well as any prolonged or violent sensory stimulation became popular, even as the obsession with speed grew toward the end of the 19th century. This is when the concern for news overload appeared, with journalists complaining they could no longer rest but had to be ready at a moment’s notice. Even the president (Teddy Roosevelt) acknowledged the burden of always having to be “on” in his 1899 book The Strenuous Life. The constant competition was acknowledged by some to keep many on edge without the ability to rest. If that weren’t enough, the second half of the 19th Century brought increasing importance to career ranking and climbing the corporate ladder. Women were still considered weaker than men in all areas.

Public education piled on more and more subjects, to the point that one social commentator bemoaned that children have a longer workday than adults and it was believed that overworking (a term coined in 1868 to describe the plight of children in schools) a child’s brain damaged it for life. Not that adults lived stress-free lives: accounts of “mental fatigue” affecting the ability to get much-needed sleep to combat the physical fatigue characteristic of more and more of society by the end of the 19th century started to make it into medical and personal literature. It’s even acknowledged now that “nervous exhaustion of the brain” (called by the new word “neurasthenia”) can be the cause of all sorts of physical ailments. The feeling of vulnerability from exhaustion and sense of mismatch between people and their environment directly contrasted the roar of mechanized progress going at full steam ahead in the late 1880s.

Psychological Symptoms of Exhaustion

Neurasthenia, first diagnosed in 1869 and called “American nervousness,” was not just an individual affliction but one affecting the entirety of society, believed to be caused by the constant overstimulation of ceaseless production. Finally, more attention was paid to the psychological symptoms, breakdowns that had not been previously described as sources of fatigue. Research turned its focus to the mental; perception and consciousness began to be scrutinized for the role and influence it had on exhaustion. After centuries of focusing exclusively on the physical effects and causes of fatigue, the study of the intersection of the physical and the mental had finally begun.

The impacts of physical and mental well-being were now considered in the workplace, but bosses insisted that fatigue had been steadily declining even as workers stated the opposite, which Vigarello claims is the central paradox of modern society. If that’s the case, I would posit that it set up post-modern society’s greatest paradox to be that it promises leisure, convenience, and ease through technological advancement, which has done nothing but pressure us all into believing we can be free of all limitations and to experience serious mental and emotional distress if we do not.

Another thing that set us post-modern citizens up for the totally unattainable ideal of human life—that is, an easy life without any limits—was that the second half of the 19th century saw manufactured substances as remedies for fatigue. Cocaine was discovered in 1855 and was widely prescribed by physicians after 1880: many believed that sipping a cocaine and wine cocktail with every meal would restore healthy sleep patterns, increase productivity, and “almost completely eliminate the painful feelings of exhaustion and helplessness caused by neurasthenia.” In the quest to restore vitality, other compounds, like powdered opium and variations of strychnine, also started getting widely used as treatments for mental and physical fatigue. The main remedy was the suggestion that fatigue could be overcome by willpower and a change in perspective. Vigarello doesn’t adequately consider the impacts of both of these developments on today’s society: could the widespread use of manufactured substances have paved the way for today’s Big Pharma? Could the reliance on willpower and perspective shifts portend the rise of psychiatry and psychology with all their attending imbalances of power and penchants for abuse?

20th Century: Office Work and Introspection

It wasn’t until the 20th century that society began engaging in full-on naval gazing. Fatigue was now seen to arise from obstacles to self-fulfillment and a generalized source of drain, physically and mentally. The tables had finally turned: instead of fatigue being purely physical with no introspective component, now the way our circumstances affected us physically became the prominent starting point and it was hard to visualize daily life without the idea of fatigue. Again, Vigarello doesn’t reflect on the effects of this mentality: might it be that this perspective is where some mental health advocates get the idea that “diabetes is like depression,” as if depression is a Prozac deficiency like diabetes is an insulin deficiency?

World War 1 brought unprecedented levels of fatigue to the world and made it an urgent problem, and was the first instance where researchers gave equal weight between what was felt and what was observed. From then on, fatigue had secured its place in the realm of psychology. The 20th century brought the rise of office work and with it, poorly designed equipment which contributed to worker fatigue. Research into fatigue continued to take a more personal focus, studying interpersonal relationships as well as relationships between staff and supervisors, and how their structure contributed (or not) to well-being.

During the interwar period, researchers detected that workers felt more beaten down and depressed than angry. Advances in technology created more kinds of fatigue rather than relief for workers. Occupational psychology, only a few decades old, had made big advances too. Psychological solutions became the most common remedies, but often, at least for women, they pointed toward emotional connections rather than substantial actions or structural changes. As researchers studied the effects of WW1, they created a category of fatigue called “stress,” which quickly led to the widespread understanding that the cause of fatigue was the modern way of life rather than physical exertion. The relationship between the physical and mental was now understood to be reciprocal and the field of endocrinology took off in the 1920s and 30s. This quickly led to the widespread reliance on substances like amphetamine by everyone from athletes to academics to military personnel (including both Axis and Allied powers) more than mindset changes, leading to serious side effects and addiction, all in the name of fighting the enemy of fatigue.

The brutality of WW1 saw the fruition of the idea of incremental human perfectibility and paved the way for cruelty against weakness, imperfection and totalitarian intolerance of frailty in general, including fatigue. The idea of the “new man,” a Spartan-like, consistently strong and perfect human, arose from the ashes of WW1 and brutally exterminated those who did not fit this description: the weak, anyone society decided was “dangerous” (so, very often people experiencing mental and emotional distress because it suggested that something was not quite right with society), the “degenerate.” The totalitarian societies of the 1930s weaponized the fatigue of the undesirable masses; German workers were afforded work breaks and vacations (the workers did not choose the time or destination and it was full of rigid programming promoting national socialism) so they would not lose their stamina and become fatigued either mentally or physically.

Mid to Late 20th Century: Stress, Burnout and Lack of Security

Society after World War 2 finally saw developments like retirement plans and ergonomic overhauls of workplaces, which focused much more on workers’ physical and mental well-being than productivity. The goal was now to design a comfortable place to work and remove all effort from any exertion a worker needed to do. The term “psychosomatic” entered usage in the 1950s to describe the very individualized ways that people, based on personal history and circumstance, experience fatigue, which led to a regressive, even primordial definition of fatigue. “Stress” took on emotional dimensions even as well-being took ever more economic ones; the proliferation of material options led to decision fatigue. Fatigue in general permeated society, provoked by the renewed sense of an “inevitable” societal progress toward utopia, but showed up differently depending on social status: for some, it was a void that could not be filled; for others, it was a striving for something better; for others, it was an overwhelming sense of defeat.

The question regarding why people felt so empty in the first place remained open. One hypothesis was that people were setting unreasonable goals, but the reality was also that working conditions, shipping jobs overseas, companies relocating without warning, the increase in temporary jobs, the myriad company policies and guidelines that lacked a clear way to follow up if a worker had questions and the spread of digital surveillance technologies still crushed individual initiative, which the rise of constant digital tracking and monitoring in the 2000s compounded. This led to the rise of workers experiencing burnout; in 2017, the word “stress” was the first choice for 78% of workers when asked to describe their relationship to their work. Burnout doesn’t always come dramatically; many endure repetitive symptoms of anxiety, constant checking/second-guessing of behavior/reactions, etc. This started to show up in the literature as sleep disturbances, daily frustration, inability to recover inner strength and more.

The “benefits,” including healthcare and retirement were the flip side of a miserable coin that involved the employer controlling everything about one’s schedule and work while at work for one’s entire career. Computerization results in a higher workload, a demand to move at a faster pace and more hardship—and thus, more fatigue; technology has not ushered in the era of convenience and ease it promised in its early days it would. The veneer of “flexibility” and “freedom” hides the constant struggle, unpredictable schedule and expectation of constant availability the technologized world has imposed upon contractors; presaging the future of work in general. Power that once had been with workers has been transferred to managers and supervisors, who are trained to put company profits before employee well-being, further alienating people from their work, which has continued to be exhausting, depressing and anxiety-provoking even with labor reforms. Waves of massive layoffs, downsizing and transferring, which employees experience as betrayal, lack of security, an affront to value and identity and helplessness in the face of huge power imbalances, have provoked large amounts of suicides in workers as well as depression, anxiety and other mental health conditions in many more.

Fatigue has always been in the background, infiltrating everywhere, never to be finally beaten, ruling our choices and life paths—and the pharmaceutical industry has taken advantage. The prescription drug market, including antibiotics and anti-anxiety medications, tripled between 1990 and 2017. All the while, we have not been taught the histories that matter—one in particular, the history of fatigue. Vigarello presents a unique perspective on history and how it’s shaped fatigue—his book is worth reading to not only consider how fatigue has shaped our individual stories as well as our history as a species, but also how we have not been taught the impact of such narrative-shaping in general. We may know we’re tired, but reading Vigarello’s work invites us to ask how much of what we think we know about why we’re tired is part of a larger narrative, one we weren’t taught to be aware existed.

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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