"Shattered Nerves:" Doctors, Patients, and Depression in Victorian England.

Janet Oppenheim's "Shattered Nerves" is a study of the meaning of depression in English culture during the Victorian and Edwardian years (c. 1830s-World War I). Using an empirical methodology that ranges widely in medical and literary sources, Oppenheim demonstrates how the metaphor of nervous exhaustion was understood by both medical and lay figures and how the connotations of "shattered nerves" changed between the early nineteenth century and World War I due to the combined impact of evangelicalism, industrialization, and psychiatric and physiological ideas.

Oppenheim works from the "illness as metaphor" perspective, portraying illness as a compound of biological reality and cultural attitudes. She notes, as have previous historians, that metaphors are particularly apt when applied to psychiatric disorders because such ailments cannot be described adequately without considering non-physical evidence. The cultural biases of psychiatrists have thus created a fertile field for medical historians exploring social definitions of illness.

Oppenheim provides an overview of British medical history during the nineteenth century, highlighting the origins of British psychiatry and the gradual and incomplete separation of the psychiatric and neurological specialties by World War I. She discusses the somatic school of medicine that tried to find a physical basis for nervous and mental diseases, the moral-pastoral role of alienists (the first psychiatrists), and the numerous specialties that tried to market their skills to nervous patients.

Oppenheim selects the life and work of Sir James Crichton-Brown to portray representative views of Victorian and Edwardian psychiatry. Crichton-Brown, whose public reputation transcended his relatively unoriginal medical career, serves as a window into the key controversies and developments that occurred in psychiatry and neurology during a career that lasted from the early 1860s to 1922. His propensity to combine medical with social and cultural ideas typified turn-of-the-century British medical thought. Crichton-Brown periodically reappears in subsequent chapters, a technique that provides thematic continuity but occasionally interrupts the narrative flow.

Other chapters deal with the central metaphor of "nervous bankruptcy" and its treatment. Known clinically as neurasthenia, nervous bankruptcy was thought to result from depletion of nerve force stemming from such varied causes as overwork, sexual excess, autointoxication (primarily overindulgence in food, drink, and tobacco), mental strain, loss of loved ones, and faulty heredity, all of which crippled the patient's will. Treatments designed to restore depleted nerve force and will power were directed at both the body and the mind (though hypnosis and later psychoanalysis found little favor in Great Britain). British treatments for neurasthenia were similar to those in the United States, a comparison Oppenheim does not explore. A little more differentiation between British and American (and other) views of nervous bankruptcy would have made clearer what was peculiarly British about British medical attitudes toward neurasthenia.

Oppenheim provides insightful discussions of the ways Victorian and Edwardian physicians understood nervous prostration among male and female sufferers as well as in children. As in the United States, widely accepted cultural stereotypes played an important role in medical theories. Psychiatrists identified the primary cause of neurasthenia in men as overwork, which carried positive connotations, and in women as reflex results of reproductive disturbances. Physicians equated children with women (both lacked mature wills) and believed that nervous women begat nervous children, thus imperiling the future of the race. Medical jeremiads about race suicide and racial deterioration were the result, as Oppenheim demonstrates. Here, too, medical attitudes were virtually indistinguishable from prevailing cultural ideas concerning the necessity of will and stamina in promoting national efficiency and ensuring Great Britain's success.

Oppenheim takes positions on several contentious issues that have occupied recent medical historiography. She criticizes the spermatic economy concept, rejects the physician as autocrat interpretation and more broadly the social control model, and argues that the stereotype of sexually repressed Victorians is overstated. She also questions the argument that women used invalidism as rebellion, believing that this interpretation leads to a simplistic equation of women with sickness, one that obscures the more complex meaning of female invalidism in an industrial society characterized by the separation of the home and workplace that redefined gender roles.

Oppenheim's empirical approach is useful for evaluating textual evidence difficult to place in predetermined categories. The study is strong on description and includes highly personal portraits of depression that make compelling reading. Clearer distinctions between British and the large literature on non-British medical thought and practice would have advanced the study beyond the state of current scholarship. As it is, scholars in the field will find much that is familiar. But while little new ground is broken, Oppenheim's solid book provides yet another example of the interpretive value of medical metaphors for historians.