A typical approach to the examination of the history of medicine involves constructing a time line upon which are placed a series of breakthroughs which are judged for their contribution to current knowledge. This purely technical rationale does not provide the insight that a social history can, in which the events of the time are firmly framed and discussed in light of the prevailing social, political and economic circumstances. The medicalisation of psycho-social and sexual problems by western medicine in the broad timespan between 1800 and 1930 is an ideal situation through which to examine this concept.
To medicalise something is to label it a disease or a disorder, and the implication then is that this can be cured by the knowledgable treatment of a physician. It will be shown that the way a number of social, sexual and psychological disorders, such as anorexia nervosa, masturbation, homosexuality and suicide were medicalised was as much a result of social framing as ! scientific progress. Under this system legitimacy and institutionalisation is given to the prevailing social order.
Further weight will be added to the case by examining how the medicalisation of womens problems closely relates to the standing they held in Victorian society. Homosexuality is a kind of behaviour which is highly amenable to examination as an example of psycho-social and sexual medicalisation. It was first detailed in American and European physicians case studies in the late nineteenth century (Hansen, 1992). Throughout history homosexual behaviour had been regarded as deviant, and was firmly in the sphere of morality.
At different times it was viewed with bemusement, for example a scot named Lithgow wrote Sodomy… monstrous filthiness, and yet to them a pleasant pastime, making songs and singing Sonets of the beauty and the pleasure of their Bardassi, or buggerd boys (Taylor, 1953:150), or disgust as an unnatural vice. The most common approach throughout the medieval years was that it was a mortal sin. The medicalisation of this condition involved conceptualising homosexuality as a blameless disease.
This necessitated a shift in its definition, whereby a homosexual was defined not as one who had performed sexual acts with a me! er of the same sex, but as someone possessing an underlying or innate sickness. Hansens (1992) reproduction of a case study of Mr. X by a physician at a New York lunatic asylum provides a good source to demonstrate this. Mr. X is described as never having had a homosexual encounter, but of exhibiting cross gender tendencies, such as nibbling food, dressing stylishly, admiring men and discussing womens dress. These characteristics were evidence enough to pronounce that the patient exhibited evidence of contrary sexual instinct (Hansen, 1992:109).
When gender is considered some interesting points emerge. The majority of diagnosed cases were male, and this may have contributed to the transformation of homosexuality into a guiltless condition, whereby its sufferers were offered social justification for their feelings. As will be discussed later in this paper, conditions which predominantly affected females often had a more oppressive outcome when medicalised. The medicalisation of suicide follows broadly similar lines to that of homosexuality, with several important exceptions.
It was regarded as a mortal sin in England in the seventeenth century, arguably because the crown could then confiscate the deceaseds property and because it was the view of the Protestant religion. MacDonald (1992) argues convincingly that the social perception of suicide, as measured through the decision of juries on suicide trials, altered dramatically over the next two centuries to the point were a complete turnaround had occurred. Initially, the great majority of juries ruled that the suicider was guilty of association with the devil and hence liable for killing themselves.
The minority of juries acquitted the defendant as non compos mentis – insane and not liable. By the early nineteenth century, when the law was abandoned, it had reached the point where every defendent was acquitted. Thus medicalisation had occurred by default (MacDonald, 1992:97)! . Physicians in fact played no part in this transformation, it was entirely socially and morally driven – the common people decided that suicide was in fact caused by disease and put it into the domain of the doctor, whereas with homosexuality the driving force came from within the medical profession.
Another difference was that unlike with homosexuality, which had its diagnosis changed from an act to a condition, suicide was diagnosed by an act; if a person killed themselves, then they must have been sick. What the two have in common is that they both expand the boundaries of legitimite illness to include deviance (Rosenberg, 1992:85). In addition to homosexuality and suicide, another completely psycho-social problem medicalised was anorexia nervosa, although this was not common. Anorexia only really spread after World War II (Brumberg, 1992).
Masturbation, which has been dissaproved throughout most of history was also made a disease, and became the subject of almost fanatical attention by nineteenth century American and British doctors. The treatment methods advocated by scientific medicine seem more brutal than any punishment meted out in other times. For instance, gynaecologists recommended hot water enemas, leeches applied to the vulva and cauterisation of the clitoris (Dally, 1991:162) and went as far as cliteridectomy, or removal of the organ (Dally, 1991:162).
Males with the condition could receive infibulation of the foreskin, have a chastity box fitted, or even a device which would alert parents with an electric bell if the son had an erection (Taylor, 1953). In addition, it was commonly held b! y physicians that masturbation led to acne, impotence, consumption, locomotor ataxia, syphilis and even death (Peterson, 1986). From todays perspective it is quite apparent that this response was a use of scientific knowledge to reinforce societys taboos.
With the upheavels occurring in society medicine became the means through which disorder could be transformed from something decided from above to something seemingly democratically arrived at through an impartial arbiter. Psycho-social and sexual disorders all have a moral element – this did not disappear when they were medicalised, they were merely framed differently. The issue of discrimination based upon gender differences falls under a social umbrella. If it can be shown that medicinal practices influenced or reinforced broad social perceptions of gender differences then they can said to be closely related.
An examination of the practice of medicine in Victorian England and America, from around 1800 to 1930, provides ideal material to build such a case. A characteristic feature of the scientific view of sex differences is its focus on the physical. The commonly held view was that behavioural differences were the direct result of the “relative proportion of mutually opposed attributes” (Moscucci, 1990:28). Men were dominated by the brain and women by the sexual organs, and this led to personality differences. A man was in control, intelligent and rational, whereas women were emotional, vulnerable and wayward.
This idea was expressed in its extreme by Michelet in 1881 when he postulated that women were in fact a pathological specimen of h! uman being (Moscucci, 1990). A woman’s actions would become even more out of control at times when her sexual organs were active, such as during childbirth, menstruation and puberty. Because behaviour was a direct result of physical structure, doctors believed they were justified in bringing psycho-social disorders into their domain. It is now pertinent to look at how this construction of behaviour influenced the clinical treatment of women.
It is not surprising in light of the previous discussion that it focused on the sexual organs. The extent of experimentation on, and removal of, womens genitals in this period is great enough to lend support to the idea that women suffered from the processes described in this paper more than men. The clitoris is the direct source of a womens enjoyment of sex, and because it was believed that this was influential on her mental state they were often removed to counter purely psychological or sexual complaints.
As Dally (1991) states, this had occurred throughout history as primarily a religious ritual, but in the late nineteenth century it took on an ideological bent. Clitoridectomies were performed for patients who masturbated and those diagnosed as nymphomaniacs, as well as the insane. Dr Isaac Baker Brown was an advocate of this treatment and was able to run a clinic which dealt almost exclusively in the operation (Moscucci, 1990). Ovaries were also much distrusted by physicians of the time. Dr. Robert Battey espoused removing ovaries to cure insanity in his 1873 wo! Female Castration (Floyd, 1997).
Young female epileptics were particularly likely to receive an ovariotomy (Dwyer, 1992). The readiness of surgeons to perform these kinds of operations has created controversy over whether there was some kind of misogynistic tendencies among the profession or society at large. Dallys description of three other operations lends considerable weight to this idea. Firstly, the glossodectomy, which involved slicing a woman’s tongue down the middle in order to divide the muscles, would result in a decreased ability to talk rapidly.
This ‘cure’, or should that be punishment, for a woman who talks too much forces her to behave in a socially acceptable way. A similar operation was performed on the hands of kleptomaniacs, who were always women, in order to prevent them from stealing small objects. The other operation described was on a woman with gyromania, the disordered rage for waltzing. Several muscles in her buttocks and calf were severed, w! ith the result that she became as complete an ornament to her sex as any charming woman can well be (Dally, 1991:159).
Most accounts of the emergence of gynaecology take one of two tacks. The first is the standard historiography which sees it as an honourable field dedicated to the improvement of women’s health, such as Guy Williams’ The Age of Miracles (1981) or Wyndham Lloyd’s A Hundred Years of Medicine (1968). Secondly, the development of Feminist literature and a re-examination of the issue through different eyes has seen a number of damning works released which paint the field as one based on the systematic domination and mutilation of women.
Coral Lansburys article ‘Gynaecology, Pornography and the Antivivisection Movement’ argues that women related to the animals being vivisected because they too were frequently strapped to tables by doctors and cut up with a knife. The evidence would seem to suggest that the latter viewpoint carries an element of truth which the former ignores, but is an insufficient explanation on its own.
This can be demonstrated through the case of hysteria, whic! ncapsulates the notions mentioned above; that womens sexual organs dominated them, that disorders with physical symptoms could be treated by surgery and that there was strong moral quotient involved. Hysteria is a psychological disorder which manifests itself physically in a variety of ways. In Victorian times, this was principally in the form of fits or paralysis (Dally, 1991), and the disorder neuroasthenia is closely related. The Weir Mitchell Rest Cure sought to treat the disorder through five elements; rest, seclusion, food, massage and electricity (Poirier, 1983).
As Poirier (1983) has shown, the prevailing view of womens physiology and social role meant that a number of women treated by this method suffered serious damage. They did not require physical recuperation from overwork but were actually suffering from a variety of mental disorders such as depression to agrophobia. The emphasis in the treatment was on returning women to their subserviant role in the home! , in contrast to the positive reinforcement given to men. Hence, the sexist Victorian attitudes were manifested in the medical treatment given.
This discussion would suggest, then, that women were certainly affected in a more adverse way by the medical professions adoption of psycho-social and sexual disorders. The question over whether this was deliberate or a subconscious reflection of dominant social mores is more difficult to resolve. There is a tendency to sensationalise the sexual aspects of nineteenth and early twentieth century medicine in Victorian England and America and paint the medical profession as a monster. Certainly the cases above suggest that society as a whole held views which were conducive to physicians medicalising these disorders in the way they did.
The nature of the operations performed, for instance the overiotomy which was the first common abdominal surgery, required a certain type of person. Some authors think this person would have had to be cold-hearted and perverted. To a certain extent this is undisputable, because some practitioners were, but it is most likely that they were in the m! inority. These people, for example Dr. William Acton (Peterson, 1986), did derive some kind of legitimacy from the conservative sexual and social environment, but they were taking it to extremes.
Peterson (1986) has argued that balancing this group were physicians who were generally humane and primarily concerned with their patients wellbeing. This silent majority has been ignored because their practices and discoveries were less sensational, and reflected the underlying sexism in a less brutal way. In order to resolve this issue the area of normal medicine should be incorporated, that is the treatment of purely physical complaints. The same methods which were used to control social, psychological and sexual disorders were in fact extremely useful in advancing womens health in other areas.
Ovariotomies were initially performed because they had become cancerous or developed large cysts, and the successful procedures developed have saved many lives. J. Marion Sims, the father of American gynaecology, has been accused of wanton experimentation on female slaves and sadistic torture (Dally, 1991). Yet these actions perfected the technique of repairing tissue torn during difficult childbirths. It is therefore counterintuitive to state that there was a deliberate agenda on the part of the predominantly male medical profession to suppress and humiliate women.
A simple comparison with the medical science conducted in Nazi Germany, a medicine of murderous experimentation, confi! rms this. No scientific progress was, or could be made under this kind of situation. The degradation, which affected females to a greater extent than males, was an unfortunate extension of what was good medicine into areas it was not suited to. It is understandable in the social context of the day, when the scientific-technical-industrial complex was gaining dominance over traditional institutions of social control.
The external encouragement physicians received for their medicalisation of these disorders came in two forms. In the first form it is actually the product of direct social opinion, such as in the above case of suicide. In the second form, it was the willingness of patients to subject themselves to often extremely painful surgery in the hope it would lead to some relief, such as in the case of the Weir Mitchell Rest Cure. It seems correct to say, therefore, that medicalisation of psycho-social and sexual disorders in this period was the product of both external social pressures and the discretionary acts of some zealous physicians.
That similar issues are still unresolved today speaks volumes. Conditions like attention deficit disorder and anorexia nervosa still occupy a kind of limbo in medical science. Indeed one could argue that anorexia is social disease which has a set of symptoms closely related to the social perception of women, similar to hysteria and neurosthenia 100 years ago. Although they have shifted in substance, the kinds of forces which resulted in women suffering more than men still exist.