The famous French philosopher Michel Foucault first rose to prominence by asserting that a Great Confinement of the mad was one of the defining features of the eighteenth century. Like many of his oracular pronouncements, the claim was factually mistaken, but on this occasion he was only off by a century or so. All across Western Europe and North America, the first half of the nineteenth century witnessed what David Rothman has called “the discovery of the asylum.”1 Differences in national cultures and political and social structures meant that the pathways to the incarceration of the insane in what was held to be a therapeutic isolation varied considerably, but the new commitment to locking up the lunatic, most often at state expense, could be seen in France and Germany just as easily as in England or the United States.
Here was a transformation of social practices that at the outset was marked by an almost utopian optimism about what the new asylums could accomplish. Experiments with a variety of non-medical interventions collectively known as “moral treatment” led contemporaries to conclude that grave forms of mental illness were in reality more curable than the physical disorders with which the medical profession generally wrestled. In legislatures, in the popular press, and in the writings of medical men, it was Bedlam madness that drew most of the attention. The problems of the raving, delusional, hallucinating madman, and the withdrawn, desolate, perhaps suicidal melancholic, for a time largely displaced the hysteric from the public stage.
Nor did the asylum vanish from the scene as the Victorian age grew to maturity. On the contrary, what had often begun as a series of small, charismatically run therapeutic establishments morphed into a vast network of museums for the collection and exhibition of the ever expanding ranks of the irrational. Legions of lunatics emerged to populate the wards of what increasingly came to be seen as warehouses of the unwanted, and a whole new group of medical specialists—variously calling themselves asylum superintendents, medical psychologists, alienists, and eventually psychiatrists—emerged to minister to these diseased minds, and to rule like petty autocrats over the miniature kingdoms of the mad that now pock-marked the countryside.
Yet, even when professional and public attention was largely focused elsewhere, the nervous and the hysterical did not entirely disappear. On the contrary, nervous patients remained a staple of general practice in the early 1800s. In an overcrowded medical marketplace, demanding hysterics who sought attention for a wide range of mysterious and recalcitrant ailments could on purely economic grounds prove a boon, however frustrating their ailments might otherwise seem. Nervous irritability and strain provided an all-purpose explanation for the hysteric’s troubles, one that comfortingly located her (or more occasionally his) complaints in a somatic framework that satisfied both doctor and patient. If such patients became overtly delusional or violent, or threatened self-harm, the general practitioner now had the option of referring them to his professional brethren who oversaw the madhouses. But, in the meantime, the doctor had at his disposal a variety of weapons to employ in the treatment of the sane but troubled hysterics who sought his attention—at least if they had the good fortune and good manners to come from the affluent classes.
There were pills, of course, all manner of pills. Nerve tonics. Iron. Strychnine. Quinine (or the Peruvian bark). Arsenic might be mobilized to provide a therapeutic jolt to shattered nerves. “Blue pills”—calomel, or mercurous chloride—might be employed to purge the nervous system of its toxins. (Benjamin Rush, the first American physician to write on diseases of the mind, was emphatic in his endorsement: “Mercury acts in this disease by abstracting morbid excitement from the brain to the mouth … conveys morbid action out of the body by the mouth, and thus restores the mind to its native seat in the brain.”2) And then there were the opiates—laudanum, morphine, and the like—all of which possessed, as a contemporary guide for the laity put it, “the wonderful properties of mitigating pain, inducing sleep, allaying inordinate action, and diminishing morbid irritability.”3 There were pills to produce vomits. Diuretics. Aperients. And in the first half of the nineteenth century, until medical confidence in the remedy plummeted, there was bleeding, by lancet, cupping, or leeches.
Still other therapeutic possibilities beckoned: the bracing effects of tonics could be reinforced by a change of scene—sea air, perhaps, or the pure air of the Alps, combined with the distractions of new and pleasing surroundings. Cheyne’s prescriptions of bathing and drinking the sulfurous waters at Bath were updated. German spas became a particular favorite of nervous patients and their professional advisers, but there emerged all manner of hydrotherapeutic establishments catering to the nervous in less exotic domestic settings as well. Water was, for many, a sovereign remedy, employed by medical men and lay speculators alike. It could be hot, cold, or tepid; sprayed, soaked in, or administered through wet sheets or towels; or even drunk for its mineral content. Nervous irritation could thus be calmed, and then the body given new vigor, perhaps by a cold bath or shower. Hydrotherapy was an all-purpose remedy, and its only drawbacks were its associations with quackery (something that deterred many mainstream physicians from employing it), and the fact that, whatever temporary relief it offered, ultimately most patients lost faith in its healing powers.
Yet hysterical patients, while often lucrative, seldom seemed to get better. As often as not they blamed their continued debility on the failures of those treating them, and sought out another opinion, sometimes consulting a dozen or more practitioners in turn. Such antics, and the implied reproach to medicine’s powers, scarcely endeared them to the profession. And in other ways they were perceived to be singularly unrewarding patients: peevish, constantly complaining, with a mass of chronic, non-specific troubles, their protracted invalidism and frequent ingratitude were wearisome and provoking.
If patients could (and did) blame their doctors for their troubles, medical men could return the favor with interest. Discomfort over the impotence of their remedies against such intractable disorders could easily spill over into anger at those who seemed so determined to remain invalids, and more than a few doctors began to harbor the suspicion that their hysterical patients were perhaps not such innocent victims after all. What if hysteria was not a purely somatic disorder? What if it were a psychological condition, even a willful retreat into illness? Then the very nature of the therapeutic encounter must and did change, for these men regarded the very notion of a psychological illness (in Szaszian fashion, avant la lettre) as a contradiction in terms, a category mistake. Either symptoms were the product of a real, physiologically based pathology, or they were a form of fakery, a manipulative malingering and deceit that deserved scorn and moral opprobrium, if not worse. And worse was indeed forthcoming, in the form of treatments whose sadistic qualities hint at the not very deeply buried professional fury that may have prompted them. Take, for example, W. Tyler Smith’s prescriptions for the nervous, menopausal women who crowded his waiting room and consultation chambers. Their erotic and nervous symptoms ought to be dealt with, he suggested, “by a course of injections of ice water into the rectum, introduction of ice into the vagina, and leeching of the labia and cervix.” His approving comments on the latter intervention rather give the game away: “The suddenness with which leeches applied to this part fill themselves considerably increases the good effect of their application, and for some hours after their removal, there is an oozing of blood from the leech bites.”4
At about the same time, Robert Brudenell Carter set up shop as a young general practitioner in the then leafy environs of Leytonstone, east of London. In later years Brudenell Carter would go on to achieve distinction as an ophthalmologist, but, like many an impecunious newly minted doctor, in his twenties he had perforce to take whatever customers presented themselves. As for many of his fellow practitioners, these included a not inconsiderable number of cases of hysteria. As his frustrations with these patients (who were almost all women) mounted, he came to change his views on what was wrong with them, and finally ventured to put his ideas and conclusions into print.5
6. Robert Brudenell Carter (1828–1918) as an ophthalmologist and an old man, many years removed from his youthful book on hysteria and its treatment. (Wellcome Library, London)
The impact of one’s emotional state on one’s bodily health had been a cliché of Hippocratic and Galenic medicine. Strong emotions could disrupt the equilibrium of the body, as could readily be seen in cases of extreme fright or fear, and Brudenell Carter suggested that they could likewise produce the “primary paroxysm” that marked the onset of hysteria. Here was the important source of the far greater frequency of hysteria among the female of the species. For “the general predominance of reasoning and feeling [among men and women] respectively, is universally acknowledged.”6 Men think, women feel. And yet civilization insisted that women, “if unmarried and chaste,” must suppress the most powerful emotion of all, “sexual desire.” While
man has such facilities for its gratification, that as a source of disease it is almost inert against him, ladies labour under the modern necessity for its entire concealment … [Thus] it is likely to produce hysteria in a larger number of the women subject to its influence than it would do if the state of society permitted its free expression.7
In and of itself, Brudenell Carter’s conclusion that “the sexual emotions are those most concerned in the production of the disease”8 did not necessitate a break with the idea that, at bottom, hysteria was a disorder rooted in the body. But he now introduced a distinction that made hysteria’s ontological status much more suspect. The initial hysterical fit might indeed be traced back to physiology, but, as the natural history of the disorder unfolded, it underwent a subtle shift. By degrees, the primary disturbance developed secondary and then tertiary manifestations. Secondary attacks were provoked by the recall of the emotions that had produced the original attack, and could sometimes be deliberately induced by the patient. Tertiary attacks always took this form, being deliberately instigated by the patient:
Attacks of this kind may be distinguished from primary hysteria by the frequency with which they occur in the absence of any exciting cause; by their never being produced under circumstances which would expose the patient to serious discomfort or real danger, but at a time and place discreetly chosen for the purpose; and by observing the many little arrangements contrived in order to add to their effect … their number and variety depending upon the ingenuity of the performer, and the extent of her resources.9
These hysterical patients were thus simulating illness, often adopting into their performance symptoms inadvertently suggested by their medical attendant or by illnesses they had witnessed in other people. Such behaviors were deeply ingrained in the patients’ psyches, and extraordinarily difficult to dislodge. The infliction of physical pain as a deterrent was useless, “since the patient herself often inflicts upon herself much more pain than any medical attendant could possibly propose.”10 But, for all that, tertiary hysteria was the product of “selfishness and deceptivity.”11 Indeed, such was the moral depravity of those exhibiting these symptoms that they arranged to satisfy their “prurient desires” by exploiting medical men’s belief in the gynecological origins of their sufferings:
I have … seen young unmarried women, of the middle class of society, reduced by the constant use of the speculum, to the mental and moral condition of prostitutes; seeking to give themselves the same indulgence by the practice of solitary vice; and asking every medical practitioner … to institute an examination of the sexual organs.12
Paragons of moral obliquity, most hysterical women were thus blameworthy, not sick. They were actresses, not real invalids, and yet they clung to their symptoms with a fierceness and persistence that defied and defeated most medical men’s efforts to cure them. Brudenell Carter’s repugnance in the face of what he clearly saw as “falsehoods” and manipulative malingering by those with “deadened moral sensibility” was palpable, and reflected a frustration that others who encountered such creatures also voiced. His anger manifested itself transparently in his therapeutic recommendations. The medical man had to maneuver to wear out “the moral endurance of the patient.”13 Neither sympathy nor alarm should be expressed, no matter how extreme the symptoms. Rather, he should “commence by a positive assertion that she has nothing at all the matter with her, and is, in reality, in perfectly good health; her ailments being, one and all, fraudulent imitations of real disease.”14 Against this deception, the doctor must wage “mental warfare,” employing “humiliation and shame” and “threats of exposure” to encourage reformation. His must be a full frontal assault, admitting of no doubt or hesitation. “In all cases it will be necessary to use plain words, and to convey the idea of selfishness and falsehood by their simplest names, and not under the disguise of any polite and elegant periphrasis.”15 Anger or tears, indignation and violent resistance, must all be ignored, met with a calm authority that insists that it will be obeyed, and on no account should any concession be made to the “pretended illness.”
The battle could be fierce and prolonged. It was best fought away from the comforts of the domestic hearth, where family members might succumb to the wily woman’s manipulation of the symptoms of sickness, and, with misplaced sympathy, forestall the necessary firmness. Removal to the doctor’s house was a sensible means of ensuring that no misguided sentiment could interfere. Victory would in the end go to the side that exhibited the most determination and fortitude. Precautions had to be taken against the “fatal error of neglecting real disease”16—and it was this requirement, at the last, that justified medical men undertaking the battle against a disorder that was not a real physical illness, and thus did not appear to belong in the medical arena. Members of all other professions were at risk of being deceived by fits, or episodes of bleeding, paralyses and pains, and thus of giving legitimacy and new life to symptoms that must at all costs be ignored and repressed. “The process,” Brudenell Carter confessed, “is always troublesome, and often difficult, but I have yet to hear of the case, in which it would ultimately fail of success; and I offer it to my brethren as a remedy, which is, humanly speaking, certain, against one of the most unmanageable diseases they are ever called upon to contend with.”17
It was a perspective on hysteria, Brudenell Carter acknowledged, that not just patients, but also their families, refused to countenance. The simulation of sickness was so convincing, the obduracy of the patients so difficult to break down, the conviction of the relatives that the young woman was of too elevated a moral standing to engage in such deceptions, that he could but seldom put his plans into practice. Moreover, like any other doctor, were he to take more than one “nervous” patient into his home at a time, he risked running afoul of the lunacy laws, which, in an effort to protect patients from abuse, now required that only licensed and inspected asylums could confine the insane. Soon enough, Brudenell Carter moved on, applying his medical talents to other, less trying, and more rewarding disorders.
If Brudenell Carter and other general practitioners who grew tired of wrestling with the recalcitrance of the hysterical patient were tempted to dismiss hysteria from the ranks of authentic illness, others were not so certain. Researches on the nature of the nervous system had gathered pace in the early decades of the nineteenth century, and new understandings of nervous function provided an alternative basis for accounting for hysteria, one that revived its classical connections to the womb and the female reproductive organs, and did so in a fashion that reinforced the notion that hysteria was necessarily a predominantly, almost exclusively, female complaint. Most emphatically, too, hysteria was a physiologically based (and thus genuine) illness.
To be sure, nineteenth-century medical men did not require the specialized neurological work of a Charles Bell, a Marshall Hall, a Thomas Laycock, or a Johannes Müller to conclude that women were different, inferior specimens of humanity, a weaker sex whose inferiority was rooted firmly in their reproductive biology. For Victorian physicians, few facts were more incontestably established than that the female of the species was, as Carroll Smith-Rosenberg and Charles Rosenberg have felicitously put it, “the product and prisoner of her reproductive system.”18 Woman’s place in society—her capacities, her roles, her behavior—was ineluctably linked to and controlled by the existence and functions of her uterus and ovaries. To the crises and periodicities of her reproductive organs could be traced all the peculiarities of her nature: the predominance of the emotional over the rational; her capacity for affection and aptitude for child-rearing; her preference for the domestic sphere; and her “natural” purity and moral sensibility. The instability of women’s bodies that inescapably dogged their daily existence in turn profoundly affected female health, and formed the physiological foundation of her greater delicacy and fragility.
What the new work on the nerves contributed to the “scientific” demonstration of female difference and inferiority was a new way of conceptualizing and accounting for women’s heightened emotional lability and vulnerability. The English mad-doctor, George Man Burrows, had claimed in 1828 that science had authoritatively demonstrated that “the functions of the brain are so intimately connected with the uterine system, that the interruption of any one process which the latter has to perform in the human economy may implicate the former.”19 At the time they were first written, such assertions rested upon little more than bluster. Subsequent experimental work on the nervous system, however, led to the development of the notion of “reflex action,” and the associated notion of reflex irritability provided a novel way to account for women’s heightened susceptibility to emotional disorder and mental disease. Puberty, pregnancy, parturition, lactation, menstruation, and the menopause—each added to the constant shock and strain on the female bodily system, prompting in all too many cases the shipwreck of the intellect, the collapse of the will, and the dissolution of all semblance of self-control. Hence women’s susceptibility, in the words of the Harvard physician Horatio Storer, to a variety of mental defects of a hysterical sort with “neither homologue or analogue in man.”20 In general, “volition, voluntary motion and judgment were believed to be functions of the central nervous system [while] the bodily functions, including reproduction, were thought to be regulated by the reflex nervous system.”21 Women, who possessed a large and complicated reproductive apparatus and only small brains, were thus far more susceptible than the male of the species to the predominance of reflex action over rational thought.
From puberty onwards, the maturation of a woman’s body produced a major alteration in her reproductive organs, which were intimately linked to her nervous system and thence to her brain. Henceforth, she was “obedient to a special law … the victim of periodicity, her life is one perpetual change.” Latent “emotions, desires, and passions … are now established” and trouble looms. For the passions dependent upon these physical changes lurk “like the smoldering fires of the volcano, ready to burst forth at any exciting moment.”22 “Excitement” or disorders of the reproductive system thus imposed immense strain on the brain and nerves and could prompt hysteria or even outright insanity. “Just as we have special diseases of the pelvic organs in the female, so we may have functional diseases of the brain, of many and deceptive types, excited in her thereby.”23 Sex, whether coitus or masturbation, or even “improper excitement of the imagination,” creates “nervous excitement and vascular turgescence of the uterine organs,” which in turn “determine the character of the mental disorder, elevating certain of the moral sentiments, or of the intellectual manifestations to a state of extravagance.” Hence “hysterical females.”24
One particular group of medical men seized upon these ideas with relish, for such notions promised a considerable expansion of their role in ministering to the needs of their patients. For centuries, Western medicine had denigrated the very concept of specialization. Specialization was for “quacks,” irregulars who battened upon public credulity and sold patent remedies for unmentionable venereal complaints, for diseases of the eye, or diabetes, or gout. (Specialists, of course, by laying claim to superior expertise, were a major competitive threat in an overcrowded medical marketplace in which the individual practitioner had a hard time standing out.) The rise of asylum medicine had represented one minor exception to this traditional view. Mad-doctors, though, were viewed with almost as much suspicion by their medical brethren as by the public at large, their motives and competence both seen as suspect. The primary weapon they employed against insanity—moral treatment—had been developed largely by laymen who saw little value in conventional medical therapeutics, and its focus on the social psychological manipulation of the patient’s environment left scant space for treatments directed at the body. Alienists’ distinctive practice as asylum-based doctors, with its heavily stigmatized and physically isolated patient population, was thus easily seen as atypical, and their specialism accordingly as being of little concern to the medical profession at large.
The suspicion that extended to other forms of specialism was rooted in part in crassly economic considerations. In the early nineteenth century, the individual doctor had a hard time standing out from the crowd. The fear of being labeled as following a trade had led medical practitioners to reinforce earlier prohibitions against advertising their wares, conduct seen as unseemly among men aspiring to gentlemanly status. Setting up as a specialist potentially offered a legitimate way of attracting patients, as long as the self-proclaimed expert could persuade prospective customers that he possessed more experience and skill than the general practitioner in ministering to particular forms of disease and debility. It was a strategy most readily pursued by those with an easily demarcated mode of practice, and among the first to seize the opportunity this situation presented were surgeon-accoucheurs.
Gynecologists, as they began to call themselves by the middle decades of the nineteenth century, posed a particularly potent threat to the general practitioner. They ministered, of course, to some of women’s most intimate needs, and their presence at the delivery of children ensured them a recurring, highly visible, and crucial role in their patients’ lives. The advance of gynecology as a medical specialty simultaneously produced and was dependent upon the increasing place of technology in the birth process, and in approaches to the diseases of women’s reproductive organs. At a period in which the bankruptcy of traditional heroic therapeutics was becoming increasingly visible, prompting many physicians to embrace therapeutic nihilism and many patients to desert allopathic medicine for homeopathy, Thomsonianism, and a variety of other sectarian competitors, it was on advances in surgical technique and practice that orthodox medicine’s continued hold on the public perhaps most crucially rested. In gynecology, as in surgery more generally, these advances derived, in the last analysis, from two crucial developments: the use of anesthesia, beginning in the 1840s; and the acceptance in the last third of the century (though not without a struggle) of Lister’s emphasis on antisepsis. Anesthesia and anti-sepsis, particularly in combination, made the routine employment of invasive surgery possible for the first time, and allowed refinements of skills and capacities that constituted spectacular confirmation of medicine’s claims to scientific legitimacy.
Among the gynecological operators of the 1850s, few were more enthusiastic and audacious than Isaac Baker Brown, whose technical skills (and willingness to risk his patients’ lives) soon placed him in the forefront of the London medical elite. He was elected a fellow of the Royal College of Surgeons in 1848, and his operating theater soon became, in the admiring words of Thomas Wakley, editor of the Lancet, “one of the most attractive to the professional visitor in all London—admiration being invariably evoked by his brilliant dexterity and the power he displayed in the use of his left hand when operating on the female perineum.”25 The publication of Surgical Diseases of Women in 1854, and his major role in the foundation of St Mary’s Hospital, marked further steps on his path to professional prominence, culminating in his election, in 1865, as President of the Medical Society of London.
In the early 1850s, Baker Brown became one of the first to use chloroform in midwifery and in obstetrical operations. He pioneered new techniques for repairing vaginal and rectal fistulae, and for dealing with the prolapsed uterus. And, notwithstanding the deaths of his first three patients, he experimented enthusiastically with ovariotomy as a cure for “ovarian dropsy.” The predictable result of what the editor of the Lancet termed “his celebrity as an operator at once bold, ingenious, and successful”26 was to bring him a steady influx of affluent and aristocratic patients, so that by 1858 he felt secure enough to withdraw from his association with St Mary’s and to establish his own proprietary hospital, The London Home for Surgical Diseases of Women.
Like many of his colleagues engaged in the treatment of the female genitals, Baker Brown had been repeatedly frustrated and foiled in those cases in which physical pathology was complicated “with hysterical and other nervous affections …” Such women, he said, echoing some of Brudenell Carter’s complaints, “defied my most carefully conceived efforts at relief.”27 His sense of frustration was relieved, however, when he read Brown-Sequard’s lectures on “The Physiology and Pathology of the Central Nervous System,” published in the Lancet the same year the London Home opened its doors. For the first time a line of attack on these recalcitrant cases occurred to him. In keeping with the contemporary doctrine of reflex irritability, the French physiologist had argued that damage to the central nervous system might be caused by over-excitement of the peripheral nerves. Baker Brown immediately saw the relevance to his own practice: the source of his patients’ hysteria and nervous complaints must surely lie in a pernicious and all-but-unmentionable habit, “peripheral excitement of the pudic nerve”—or, to put it bluntly, female masturbation.
In invoking masturbation as a cause of hysteria and other forms of insanity, Baker Brown was scarcely advancing a novel hypothesis. Masturbatory insanity had been a staple of early nineteenth-century psychiatric texts, and had acquired new credibility in many quarters through the growing emphasis on the importance of the conservation of energy. In other hands, this theory had already been invoked to justify a number of painful, or more accurately sadistic, “remedies.” Particularly popular was the “continual application of the strongest caustics to the seat of the irritation,”28 in an effort to dissuade the patient from the filthy habit. Characteristically, however, Baker Brown scorned these sorts of half measures as wholly inadequate to “destroy such deep-seated nerve irritation” and proceeded at once to “a surgical test, by removing the cause of excitement,” the woman’s clitoris.29
This desperate remedy was justified, in Baker Brown’s eyes, by the danger that nervous exhaustion posed to the whole system. Loss of nerve power as a result of masturbation was, he assured his readers, followed successively by “hysteria, spinal irritation, hysterical epilepsy, cataleptic fits, epileptic fits, idiotcy [sic], mania, and finally death.” And the record of his operative results between 1858 and 1866 proved that “the treatment must be the same whether we wish to cure functional disturbance, arrest organic disease, or, finally, if we have only a chance of averting death itself.”30 Patients deemed suitable cases for treatment were operated upon immediately; he paused only to ensure that they had “been placed completely under the influence of chloroform” before “the clitoris is freely excised either by scissors or knife.”31 The results, according to Baker Brown himself, were enormously gratifying, and, within a month, “it is difficult for the uninformed, or nonmedical, to discover any trace of an operation.”32 Idiots, epileptics, hysterics, paralytics, the young and the old, all proved readily curable through surgical intervention. Even in cases of nymphomania, where “under medical treatment, of how short duration is … too frequently the benefit,” success was all but guaranteed: indeed, “in no case am I so certain of a permanent cure … for I have never after my treatment seen a recurrence of the disease.”33
Despite, or perhaps because of, these vaunted successes, and notwithstanding its apparent conformity with some of the central assumptions of mid-Victorian medical theory, Baker Brown’s work brought him opprobrium rather than the hoped-for fame. Within a year of his book’s appearance, both clitoridectomy and its author had been consigned to the outer darkness. Why was this?
Not, for all appearances, because of the cruelty or failures of the treatment. As Elaine Showalter points out in The Female Malady: “The mutilation, sedation, and psychological intimidation … seems to have been an efficient, if brutal, form of reprogramming …”34 and, in any event, the issue of inefficacy was never seriously pursued in the storm of criticism Baker Brown’s work raised. The treatment was certainly brutal, as is made clear in the description given by one of Baker Brown’s former assistants:
Two instruments were used: the pair of hooked forceps which Mr Brown always uses in clitoridectomy, and a cautery iron … The clitoris was seized by the forceps in the usual manner. The thin edge of the red hot iron was then passed around its base until the origin was severed from its attachments, being partly cut or sawn, and partly torn away. After the clitoris was removed, the nymphae on each side were severed in a similar way by a sawing motion of the hot iron. After the clitoris and nymphae were got rid of, the operation was brought to a close by taking the back of the iron and sawing the surfaces of the labia and the other parts of the vulva which had escaped the cautery, and the instrument was rubbed down backwards and forwards till the parts were more effectually destroyed than when Mr Brown uses the scissors to effect the same result.35
But the brutality of the surgery was likewise not the central issue, and scarcely could be, since some of Baker Brown’s fiercest critics themselves used treatments that were every bit as unpleasant with their own female patients. Instead, it was the “ethics” of Baker Brown’s behavior that drew down on his head the almost universal wrath of his colleagues. In fact, close attention to the record reveals that, even before the appearance of his book, Baker Brown’s activities had drawn unfavorable comment from influential segments of the medical press. Mid-nineteenth-century medical practitioners could lay only a precarious claim to gentlemanly status, and medical elites were thus extraordinarily sensitive about behavior that threatened the profession’s social standing. Baker Brown’s activities raised this vital issue in multiple and mutually reinforcing ways.
He had aggressively and repeatedly sought public attention for and approval of his activities. In early 1866, for example, before his book on clitoridectomy appeared in print, he had arranged with a friendly reporter for the Standard for a hyperbolic article on “An Admirable Institute—The London Surgical Home.” This immediately drew sharp criticism from the editor of the British Medical Journal, who commented tartly: “We doubt whether the profession will approve of the way in which this particular institution is brought before the public … A superfluous amount of self-laudation is not always a real recommendation.”36 Baker Brown failed to take the hint. A few issues later, the British Medical Journal returned to the attack: the recent annual report of the London Surgical Home was permeated by “a regrettable spirit of exaggeration …” And his new book on clitoridectomy, while demonstrating that “the operation may be of value in certain forms of nervous disease,” made similarly wild and unsupported claims. Equally unforgivable was the presentation of subject matter fit only for the eyes of fellow medical men in a binding more suited “to a class of works which lie upon drawing room tables.”37 The impression that Baker Brown was seeking lay, rather than professional, approval was only accentuated by the appearance in the Church Times of an article endorsing his operation and urging clergymen to recommend it to their parishioners; and by the claim that Baker Brown had sent the annual report of the London Surgical Home “to half the nobility in the kingdom.”38 And, when Baker Brown again resorted to barely disguised advertising in the public press, planting another laudatory story touting his unique remedy in cases of insanity (on this occasion in The Times on December 15, 1866), the editors finally lost all patience, and referred his activities to the Commissioners in Lunacy.
Baker Brown thus proved fatally unwilling to abandon a line of conduct that deeply offended professional norms. His relentless pursuit of publicity smacked of the tradesman, an association that medical men (especially surgeons) were desperately anxious to live down. In the fiercely competitive medical world of mid-century London, advertising—direct or thinly disguised—threatened both the economic interests and the status of the profession. Accordingly, few behaviors were so predictably stigmatized and anathematized. At least equally serious was Baker Brown’s preference for lay approval over the opinion of his professional peers. For this raised the specter of quackery, an association rendered the more plausible by the extraordinary array of hitherto untreatable conditions that Baker Brown claimed to cure.
By the close of 1866, the London medical elite was all but unanimously turning on someone who had, till recently, been one of its leading lights. As Michael Clark has rightly argued, the physician’s moral and pastoral responsibilities were an essential—perhaps the essential—foundation of the Victorian medical man’s claims to authority and prestige. Anything that cast even a shadow upon the appearance of moral rectitude and strict probity simultaneously threatened the profession’s paramount concern with safeguarding the basis of its social standing and mandate. It was his violation of this “first principle of the physician’s professional conduct”39 that destroyed Baker Brown. For the injunction to uphold the basis of professional honor was always likely to be enforced with particular force and fury in the case of gynecology, a specialty whose practitioners, as the editor of the British Medical Journal put it, “beyond other [medical] men, are not only the guardians of life, but, by force of circumstance, often also the guardians of female honour and purity.”40
The very precariousness of the position of the gynecologists, who had only just “emerged from the difficulties and clouds under which we lay during previous centuries,” made it essential, in T. H. Tanner’s words, that the Obstetrical Society should demonstrate to “the public that their health in our hands, as men of honour and gentlemen, is safe.”41 As men, and, more particularly, as medical men, gynecologists possessed extraordinary power over the weaker sex; yet their social mandate to exercise that power would rapidly evaporate were they to use their authority irresponsibly and “unethically.” As Seymour Haden put it, in proposing the notion to expel Baker Brown from the Obstetrical Society:
we have constituted ourselves, as it were, the guardians of [women’s] interests, and in many cases … the custodians of their honour. We are, in fact, the stronger, and they the weaker. They are obliged to believe all that we tell them. They are not in a position to dispute anything we say to them, and we therefore may be said to have them at our mercy … Under these circumstances, if we should depart from the strictest principles of honour, if we should cheat or victimize them in any shape or way, we would be unworthy of the profession of which we are members.42
Quite unambiguously, then, Baker Brown’s conduct constituted “a breach of faith with every individual member of the profession…”;43 a betrayal of trust that, without a forceful response from the guardians of professional morality, might have delivered a body blow to the reputation for moral rectitude and probity upon which the profession’s privileged place in the division of labor ultimately rested. Hence the harsh and unforgiving treatment by his peers. His would not prove to be the last occasion, however, when gynecologists sought to claim the treatment of hysteria as their own.