David G. Schuster's Neurasthenic Nation: America's Search for Health, Happiness, and Comfort, 1869-1920 chronicles the rise and fall of neurasthenia. Now a discredited diagnosis and removed from the DSM in 1980, neurasthenia was one of the most widely used diagnoses in the United States from the early 1880s through 1920. Medical professionals widely applied the diagnosis to their patients, producers of medicines and equipment promoted wares in order to alleviate its symptoms, and individuals claimed authority to self-diagnose their own neurasthenia. Schuster argues that neurasthenia's rise, common usage, and eventual decline reflected the larger culture's unease with modernity—the frenzy of the modern workplace, changing technologies, urban separation from nature, and contested gender and racial hierarchies.

What does being healthy involve? Neurasthenic Nation argues strongly that Americans' expectations for "good health" changed over time; were influenced by class, race, and gender; and could be and were shaped by popular culture and consumerism. As the twentieth century broached, Americans increasingly expected to be pain-free, to be physically comfortable, to have sexual lives that at least semi-matched those idealized in popular culture, to enjoy and find meaning in their wage and domestic work, and to be happy. If not, they increasingly considered themselves unhealthy, with a nervous system out of whack: in short, to have neurasthenia. While Schuster does not extrapolate in this direction, his work suggests that, like disability, definitions of able-bodiedness and able-mindedness are contextual and change over time.

The symptoms of neurasthenia were broad: sadness, irritability, indigestion, pain, impotence or a lack of interest in sex, headaches, lethargy, and general apathy. Among white urbanites, particularly those of the middle and upper classes, neurasthenia became a "fashionable illness" (3), a widely used term, and a diagnosis carrying little stigma. Building on the argument that the body's nervous energy was of limited supply, and that an insufficient supply would cause the body to dim—just like the newly invented electrically powered lightbulbs and other machinery—neurasthenia was believed to be caused by the increased demands of modernization and the resulting frenzied, urban life. Unlike insanity, stigmatized and believed to derive from individual weakness of mind and/or body, neurasthenia resulted from the demands modernity made of those fully engaged in the world around them.

Neurasthenia was, in many ways, a diagnosis of the privileged. One of its main theorists, George M. Beard, explained that Catholics (the religion of the bulk of new immigrants) were "relatively safe" from neurasthenia because, unlike Protestants, their church hierarchy made their important theological decisions and thus saved them from theological angst (22). The relatively slow pace and backwardness of Southern life inoculated Southern whites from neurasthenia, even the wealthy; and indigenous Americans benefited from their supposedly outdoor and physical life, as well as their "utter want of curiosity" (22). African Americans similarly lived primitive and physically strenuous lives, possessed "immature minds" and valued emotion over intellect (22), Beard explained, and thus were safe from neurasthenia.

S. Weir Mitchell, today (in)famous because of his treatment of Charlotte Perkins Gilman's neurasthenia which Gilman chronicled in The Yellow Wallpaper (1899), considered neurasthenia a disease of the elite. His recommended therapies generally included removal from stress and labor both physical and mental. He encouraged complete leisure, and a focus on family, literature (but not too heady), art, travel, recreation and nature. The most severe cases, like that of Gilman, required a complete rest cure of no mental, emotional, or even taste stimulation whatsoever. Few besides the wealthy could afford his fees, or the servant and nursing support required to engage in a rest cure.

In many ways, neurasthenia also was a gendered diagnosis. Treatment and diagnosis varied according to gender. Men diagnosed as neurasthenic often cited financial concerns, what they considered sexual dysfunctions (such as premature ejaculation or impotence), or a failure to meet masculine ideals of race and class. Some physicians who treated male neurasthenia sought to "redefine manliness" (94); others encouraged men to partake of activities, such as physical exercise, that would make them more manly. Neurasthenic women often blamed gender and domestic expectations discordant with their true selves for causing their neurasthenia. The solution, however, varied. For women such as Charlotte Perkins Gilman, the key was for society to modernize and redistribute housework in order that women could simultaneously explore their own intellectual lives. For Sarah Butler Wister (the daughter of a wealthy slaveholder and the actress Fanny Kemble), the solution was to embrace traditional domesticity but take periodic restful vacations away from hearth, home, and children.

The story of neurasthenia is also a story of medical authority. The identification of neurasthenia and its incorporation into medical and popular health manuals in the 1870s helped to establish physicians as authorities and professionals—particularly neurologists. The embrace of neurasthenia and neurasthenia products by commercial interests in the 1880s, its popularity as a topic for journalists and writers in the 1890s, and the resulting propensity of individuals to self-diagnose, wrested control of the diagnosis away from medical professionals. In the 1920s, aided by the development of Freudian psychology and new understandings of vitamins and hormones, physicians struck back successfully. They increasingly considered the neurasthenia diagnosis meaningless. It was too broad, too vague, too lacking in scientific rigor, they insisted. It also, however, had left their control. Part of the process of claiming professional legitimacy was (re)claiming professional diagnostic authority and expertise. Out went neurasthenia.

Schuster does not bluntly say that neurasthenia was an "unreal" diagnosis, but his work raises many questions about the "realness" of illness, disability, and diagnosis. If some diagnoses are socially constructed—contextual and/or historical—are all? If not, what is the distinction between a real illness, a real disability, and those that are socially constructed? And does being socially contextualized mean that an illness or disability necessarily is fake? Can a diagnosis, a label, be both socially constructed and real? In many ways, particularly for a scholar of disability, Neurasthenic Nation raises more questions than it answers.

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Copyright (c) 2012 Kim E. Nielsen

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