The Right to Be Sick: American Physicians and Nervous Patients, 1885-1910

Author(s): F. G. Gosling and Joyce M. Ray

Reviewed work(s):
Source: Journal of Social History, Vol. 20, No. 2 (Winter, 1986), pp. 251-267
Published by: Oxford University Press
Stable URL: http://www.jstor.org/stable/3787706 .
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 THE RIGHT TO BE SICK:
AMERICAN PHYSICIANS AND NERVOUS PATIENTS,
18854910

As historians have become increasingly interested in the private side of

American life, they have questioned the effect that gender roles have had in
determining men's and women's behavior during specific historical periods.
Perhaps no time in American history is more identified with gender-related issues
than the Victorian era of the mid-nineteenth through the early-twentieth
centuries. Analyses of Victorian gender roles have usually revolved around the
extent to which Americans accepted the doctrine of separate spheres ? men
as breadwinners, women as mothers and homemakers ? so highly identified
with the urban middle class. Related discussions have focused on the sexual
repression which has long been regarded as virtually synonymous with the period.
While historians have acknowledged that a gap existed between standards of
morality and actual behavior, the dominant Victorian ideology is commonly
presented as one of self-control for men and passionlessness for women.1 In the
absence of reliable data revealing the role behavior of "average" men and women
during this period, the influence of special interest groups has assumed increasing
significance in the study of Victorianism.
Physicians, of course, were among the most important groups influencing gender
ideology in the Victorian period. Members of the medical community took
advantage of the increasing prestige of science in general and medicine in
particular to establish themselves as experts eager to counsel Americans on a
wide range of personal issues. Thus physicians not only reflected middle-class
values but also helped to shape them. The important role played by physicians
in endorsing and legitimizing dominant middle-class Victorian gender and sexual
values has been recognized by numerous historians, among them Charles
Rosenberg and Carroll Smith-Rosenberg, John and Robin Haller, and Anita and
Michael Fellman.2 Several historians have argued that gynecologists, for example,
essentially conspired to dominate women by performing surgery on those who
challenged their "proper place" or evidenced an "unnatural" sexual appetite.
Noteworthy in this respect is GJ. Barker-Benfield's study of male attitudes toward
women, which argues that late-nineteenth century gynecology constituted an
attack on female autonomy and sexuality.3 Barbara Ehrenreich and Deirdre
English have also suggested that "radical" surgery was characteristic of
gynecological practice during the period and evidenced male hostility (and
uncertainty) in the face of expanding opportunities for women in the new
industrial economy.4 Like other scholarship dealing with the personal dimension
of Victorian culture, however, the literature focusing on medical views has tended
to rely on sources which deal with only one gender or class of patients.
Consequently there is more historical literature on Victorian women, and
particularly middle-class women, than on men, or women of other social classes.5

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252 journal of social history

The lack of controls for other representative groups has left gaps in our
understanding of Victorian culture.
The present study examines the degree to which physicians in the late Victorian
era propounded dominant gender and class attitudes through case records of
a specific patient population ? the diverse
group of patients diagnosed as
"nervous" and reported on by their physicians in medical journals between 1885
and 1910.6 These years represent the period during which the disease know as
"neurasthenia" or "nervousness" was most widely reported.7 Analysis of these
records suggests that physicians found so-called nervous exhaustion to be more
justified in some patients than others, and that their gender and class biases
influenced their perceptions of which patients had a legitimate "right" to be sick.
Physicians who wrote on neurasthenia displayed sympathy toward their patients
based on their perceptions of whether the illness was acquired through
praiseworthy or contemptible means. Physicians' specialties also seem to have
influenced both diagnoses and courses of treatment. This analysis of the
neurasthenic patient literature indicates that physicians' gender attitudes in the
late nineteenth and early twentieth centuries were more complex than has been
suggested, intermingling with both professional concerns and class stereotypes
widely held in the medical community. The measurement of relative sympathy
levels displayed by physicians for different types of patients suggests that both
patient class and gender, as well as physician specialty, must be considered in
analyzing physicians' perceptions of nervous Americans, and doubtless of other
patient populations as well.
Neurasthenia, a disease classification that came into vogue in the 1870s, reached
its peak of popularity between the mid-1880s and the first decade of the twentieth
century, and fell into disuse with the increasing attention paid to European
concepts ofthe neuroses and psychoses in the nineteen teens and twenties. When
the New York neurologist George M. Beard began his campaign to gain
neurasthenia a place in the medical nomenclature in the late 1860s, he described
it as a nervous condition caused by a combination of overwork and hereditary
predisposition characterized primarily by mental and physical fatigue, insomnia,
headache, inability to concentrate, phobias, and a variety of systemic irregularities.
While admitting that its pathological basis was unclear, Beard argued that the
disease was a product of specific features of late-nineteenth century American
society: the telegraph, the railroad, the periodical press, and the atmosphere of
political and religious liberty, all of which combined to heighten cerebral tension
and make life in industrial America particularly taxing. Beard's nationalism was
evident when he held that the predominance of neurasthenia in the United States
was a sign of achievement since it resulted from the rapid progress made possible
by Yankee ingenuity and overcommitment to the work ethic. Thus, nervous
exhaustion resulted when people worked too hard for too long. Beard believed
that the disease primarily claimed members of the urban professional class, whom
he labeled "brain-workers" to distinguish them from the laboring classes ("muscle-
workers") who represented a lower stage of cultural evolution and were therefore
less prone to nervous affections.
While Beard's American Nervousness has achieved the status of a minor medical
classic,8 the belief that neurasthenia was a disease of the upper classes, with their

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THE RIGHT TO BE SICK 253

highly developed nervous systems, had changed by the 1890s. With the growth
of hospitals and public dispensaries, physicians began to recognize the mental
and physical symptoms of neurasthenia among poor patients as well. Neurasthenia
became an umbrella diagnosis applied to a host of non-specific nervous and
emotional disorders and a disease virtually identified with the period. The
neurasthenic model, valuable because it gave credence to non-verifiable symptoms
and to emotional distress that was not outright insanity, was
dismantled when it proved too large and cumbersome to be subdivided into more
specific categories. By the nineteen teens many of the nervous disorders which
has been classified as neurasthenia were recognized as forms of neuroses, while
milder cases would today doubtless fall into the category of stress-related illnesses.
The value of neurasthenia for historians lies in the fact that so little was known
of its pathological basis that physicians* statements regarding the disease were
comprised more of social and cultural elements than of scientific knowledge. The
neurasthenia era thus provides historians with a unique opportunity to study
prevailing gender and class roles and their effects on the doctor/patient
relationship.
The authors examined one hundred and sixty-seven case records of neurasthenic
patients published in American medical journals between 1885-1910.9 These
records represented those of the two hundred and thirty-two published during
this period that provided enough information to determine patient gender and
approximate social class. (These two hundred and thirty-two patients represent
virtually all ofthe individual neurasthenics whose cases were reported in American
medical journals during the period).10 Neurasthenics represented all walks of life
from physicians, businessmen, housewives, and storekeepers to sales and clerical
personnel, and skilled and unskilled laborers from such industries as railroading
and shipbuilding.11 The patients were classified for the purposes of this study
into four subgroups, consisting of middle-class men (56 patients), middle-class
women (51), lower-class men (37), and lower-class women (23). This division, while
it places patients in two rather than the three classes usually employed by
historians, is consistent with the collective generalizations physicians made about
neurasthenic patients, whom they tended to distinguish as either professional
or working class.12 Nervous patients complained of a wide variety of symptoms
ranging from headache, indigestion, insomnia and backache to depression,
phobias and obsessions. Such non-verifiable symptoms left much to the physician's
imagination in ascertaining the cause of nervousness, and it appears that doctors
consistently filled in the gaps in their medical knowledge with their pre-conceived
gender and class biases.
Case records were analyzed to determine the cause of nervousness, judgmental
terms used to describe patients, and treatment methods employed in each case.
Evidence indicates that physicians sympathized most with those patients whom
they perceived as victims of overwork (primarily middle-class men and lower-
class women). They also sympathized, though to a lesser degree, with those
biologically predisposed to nervousness (women of all classes), but expressed little
sympathy for those believed to be guilty of vices such as sexual excess or other
bad habits (most often lower-class men). Thus a gender-by-class model expressing
physicians' sympathy toward nervous patients based on attribution of the cause

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254 journal of social history

of nervousness can be constructed (Figure A).

Predictably, the patients most often characterized as overworked ? and hence
described most favorably by physicians ? were middle-class men. Digestive
irregularities, headache and fatigue among these men were attributed to overwork
in the form of mental labor or anxiety. The tone physicians used to describe
overworked business and professional men indicates that they regarded nervous
prostration resulting from excessive ambition as justifiable. While physicians
occasionally chastised businessmen for bad habits which led to neurasthenia ?
overeating, overdrinking, and other excesses ? they most often attributed the
cause of illness in such patients to praiseworthy circumstances. Fully 69% of
middle-class men were reported as suffering from overwork and anxiety related
to business affairs (Table 1).
In his presidential address on "Nervousness" given before the Connecticut State
Medical Society in 1885, Dr. E.G Kinney discussed several cases which typified
physicians' views of middle-class male neurasthenics. One patient, for example,
was a 54-year-old factory superintendent who had "entered a machine shop at
sixteen, and had been in one ever since. For the last fifteen years he had been
superintendent of one of the largest factories in the State, and... for the last
three years had charge of building a large new factory, for which he had to invent
and construct a new line of machinery. It had been noticed for some months
past that he had been growing nervous and very irritable, he was cross and absent-
minded, constantly doing things that exhibited lack of judgment. For the last
few nights he had slept but little. He talked extravagantly about his recent
inventions."13 Kinney clearly attributed this man's condition to the strains of
overwork and responsibility despite the patient's obvious symptoms of mental
disturbance.
Other physicians echoed Kinney's sympathetic view of the hard-working male
neurasthenic. C.W. Hitchcock of Detroit, for example, recorded the case of "W.D.,
46, married, commercial traveler.... Both his family and personal history were
essentially negative. He had been a very hard worker, had covered a large territory
and had taken no vacation for eighteen years (italics supplied by Hitchcock)."14
Descriptions of professional men as being of "good habits" is common in the
neurasthenic literature, even in cases where contrary evidence was also provided.
F.S. Smith of Nevada, Iowa, for example, reported the case of "Mr. T ?, aged
sixty, lawyer; habits perfect; good family history, although his father is said to
have been very nervous. Patient has always been active and strong, mentally
and physically; given to periods of intense activity, alternating with spells of
slothful indolence"15 And Edward Hornibrook of Cherokee, Iowa provided a
classic example of willingness to overlook faults in members of one's own
profession: "H.E., physician; age 40 years; has been in practice eighteen years;
always worked hard; practice large; moderate and temperate in every respect. Never
uses alcohol except to stimulate his flagging powers when over-fatigued. This
occurs frequently.. . ."16
In contrast to these sympathetic descriptions of middle-class men, case reports
of poor male patients were likely to be written in a less respectful tone. While
reports of lower-class men tended to be briefer than those of middle-class patients,
phrases such as "glance is furtive" and "has worshipped freely at the shrine of

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THE RIGHT TOBE SICK 255

FIGURE A:
Gender/Class Model

Venus" are occasionally found. While physicians listed overwork as a cause in

26% of these cases, they reported sexual excess in 41% and abuse of alcohol,
drugs, or tobacco in 29% (Table 1). Significantly, not a single lower-class man
was considered to be suffering from hereditary nervousness.17 The cause of
neurasthenia in this group was entirely self-induced, and usually in a less-than-
praiseworthy manner. While physicians assumed that middle-class men were
overworked, or rendered susceptible to stress through nervous inheritance, they
generally ascribed neurasthenia in lower-class men to profligate habits. Margaret
Cleaves, a New York City physician who reported on a large number of cases
from her electrotherapy clinic, provides some insight into the kinds of pre-
conceived biases physicians may have had in diagnosing causes of nervousness.
Of seventeen dispensary patients reported in an 1896 article, Cleaves found that
four of the six blue-collar males she treated were suffering from "sexual
neurasthenia," while all of the four professional or business men were treated
for "cerebrasthenia" (mental exhaustion), "cerebro-spinal neurasthenia," or simple
neurasthenia.18

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 256 journal of social history
Sexual neurasthenia was the diagnosis most suggestive of degeneracy among
nervous patients. It was often applied when the patient, almost always a male,
complained of sexual dysfunction or uro-genital pain, in addition to the usual
neurasthenic symptoms. As masturbation and frequent intercourse were believed
common causes of nervous exhaustion, it is not surprising that many male patients
readily accepted the diagnosis. The fear that "onanism" and sexual excess led to
mental disturbance and eventual insanity was vividly illustrated by EB. Bishop
of Washington, D.C., in an 1891 article:

The strongcases are those in which the irritation of masturbation or excessive coition,
re-acting upon the brain for many years, has eventually, in the very prime of life
and apparent physical development, produced something more than a mere
functional disease. The patient wanders, and lingers, perhaps, for years, on the
border of mental rapture and moral responsibility, during which time his actions
and speech become what is termed by his friends peculiar, this peculiarity increasing
with time, marked by great extravagance of word and action. He eventually passes
that imaginary line, and through a portal which has for its motto that which is
said to have greeted the eyes of Dante, as he passed the entrance to the infernal
region, Abandon hope, all ye who enter here,' for I know no well authenticated
case of cure of general paralysis of the insane.
While sexual neurasthenia was not a diagnosis reserved exclusively for lower-
class men, such men were twice as likely to be diagnosed as sexual neurasthenics
than were middle-class males (Table l).20
J.A. Holloway of Round Rock, Texas, described a case of sexual neurasthenia
in 1902 which demonstrates the assumptions that many physicians and patients
made regarding sexual neurasthenia: "Mr. B., a young man about 22 years old,
of rather stalwart figure, came to me for treatment, claiming that he was unclean
and did not want to shake hands with any one. Upon a thorough investigation
of his case I found that he was a masturbator and that he was bordering on
insanity. I did not treat the young man, but ordered that he be sent to Dr.
Worsham and be placed in an institution where he could be guarded. He was
placed under the care of an attendant both day and night. After three months'
treatment he recovered and claims that he has found other means of relief and
is now a sound man."21
While physicians displayed rather distinct class biases in describing male
neurasthenics, their attitudes regarding nervous female patients were complicated
"
by prevalent perceptions of the "fair sex Women were not ultimately responsible
for their class status, being dependent upon husbands and fathers for their
positions in society. Furthermore, it was difficult for physicians to perceive
"women's" work as being as stressful as outside employment was for men. But
because it was clear that at least as many women as men suffered from nervousness,
it was necessary to find another reasonable cause to explain the occurrence of
neurasthenia in women who were apparently not "hysterical," "hypochondriacal,"
or "degenerate." That cause was biology. Local disease, excessive childbearing, or
other "female" trouble was listed as the cause of neurasthenia for 49% of the
middle-class and 40% of the lower-class women studied (Table 2).
At the turn of the century gynecoiogists still believed that gynecological
disturbances were frequent and justifiable causes of nervousness in women, a

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THE RIGHT TO BE SICK 257

NOTE: Percentages exceed one hundred because physicians sometimes listed more than one
cause per case.

theory that had been popularized earlier in the century to explain hysteria. The
argument that women could be made nervous by even minor pelvic abnormalities
offered a legitimizing explanation for neurasthenia in women who had no
"adequate" external stress in their lives. As Henry B. Deale and S.S. Adams of
Washington, D.C, explained this biological argument in an 1894 article: "[The
predisposition toward neurasthenia] is, as in all physical inheritances, merely a
tendency, sufficient probably for an ordinarily varied existence, but incapable
of great excitement or an unvaried, humdrum life. This weakened nervous
tendency inherited by a young girl or woman harassed by the ambitions of school
life or social excitements, or annoyed with household and family cares (probably
a dull monotony at best), all occurring early in a time of life when the entire
organism, nervous as well as physical, is undergoing a great strain ? all this seems
sufficient to account for the nervous depression or exhaustion that so frequently
results."22 It would seem from this view that few young women could escape
neurasthenia even in the best of circumstances. Oddly, doctors seem not to have
equated the nervous symptoms of busy women with those of overworked
businessmen but believed that the feminine sex was naturally delicate and
nervous. Although there was considerable disagreement in the neurasthenic
literature as to which ? if either ? sex was more prone to neurasthenia,
gynecologists found it easy to believe that their own clientele was particularly
susceptible.
In the case of middle- and upper-class women who exhibited no justifiable cause
for nervousness, physicians fequently diagnosed "hystero-neurasthenia" or
hereditary nervousness. Such women were often described in rather amused tones.
J.P.C. Foster of New Haven, Connecticut, reported a typical case in 1901:
A lady fifty-four years of age, had been for many years a great sufferer from articular
rheumatism. Associated with this condition was a highly sensitive nervous
organization, ready to accept any suggestion that came her way. . .. There was
nothing that could be criticized as to her past treatment, save, in my judgment,
the unfortunate suggestion that had often been made to her in a well known New

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258 journal of social history

York City sanitarium, that she was an interesting case. When this patient came
under my care she had finally given up hope of relief from rheumatism and was
confined absolutely to her room, most of the time an intense sufferer. It is worthy
of note that she was a member of the 'shut in' society, and greatly enjoyed that
singular correspondence ? in which she was competent to make herself a
conspicuous figure. After I had had the case under sufficient observation, I was
convinced that the rheumatism was a thing of the past and that all the symptoms
were due to neurasthenia. . ..

In contrast to the skeptical tone which physicians frequently used in describing

the complaints of nervous middle-class women, they displayed considerable
sympathy for poor women. Although physicians tended to regard women in
general as ethereal creatures unsuited for employment, it was a fact that many
lower-class women were forced to work to support their families. Such women,
doctors recognized, were often called upon to assume responsibilities for which
the fair sex was unfitted. In these instances doctors' gender attitudes transcended
their class biases. Working-class women were, in fact, shown more sympathy by
physicians than either lower-class men or middle-class women. They were
described in much the same ,terms as those applied to overworked middle-class
men. In one such case, for example, Lincoln Gray Taylor of Kansas City, Missouri,
described his patient as "a young woman suffering from prostration, headache,
loss of appetite, and who claimed to be too ill to leave her bed. She gave the
following history; For the past three months she had been complaining of feeling
badly, and unable to attend to her duties as bookkeeper in a downtown office.
She grew better, then worse, in a few days, and had a general feeling of being
*
run down' and exhausted on slight exertion.... Her bowels were regulated and
she was put to bed. I told her she would not be able to return to her office for
at least two months. She will remain in bed for two weeks, then she must go
to the country to recuperate."24 Overwork such as that described by Taylor was
reported for 26% of the lower-class women studied, while physicians listed
overwork as a cause of neurasthenia in middle-class women only 7% ofthe time
(Table 2).
The strain of caring for relatives suffering from lengthy illnesses was a frequent
cause of overwork among women. Henry E. Leake of Dallas reported one such
case in 1902: "A short time ago I was summoned to the bedside of a lady living
sixty miles from Dallas.... For several weeks she had been in constant attendance
upon an only son sick with typhoid fever. Worn out by constant watching and
solicitude, she had emerged from this trial without any serious breakdown when
her son experienced a relapse of his previous condition. This additional weight
of care and fear had completely prostrated her, when all the symptoms of a
profound neurasthenia showed themselves. . . ."25 F.D. Bain of Kenton, Ohio,
recalled in 1897 "the most desperate case of my observation. . ., a female patient,
55 years of age, who nursed her mother through a protracted illness. So devoted
was she to her aged parent that she gave every hour of the twenty-four to
attendance at the bed-side; day after day and week after week she remained faithful
in her vigils, when at last the fatal termination of the case occurred. The shock
was too great and this devoted daughter found herself the victim of a complet'e
nervous exhaustion."26
While physicians believed that women of limited means could truly be

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THE RIGHT TO BE SICK 259

overworked, they apparently believed that middle-class women rarely suffered

from external stress adequate to cause neurasthenia. However, many middle-class
women appeared to be nervously exhausted despite the lack of stressful causes.
Gynecologists believed that many of these women suffered from pelvic
abnormalities that accounted for their nervous symptoms. As Charles A. Reed
of Cincinnati, president of the American Gynecological and Obstetrical Society
in 1899, explained: "The genital organs of women, considered in the agregate
[sic], are nothing more or less than a central telegraphic office, from which wires
radiate to every nook and corner of the system, and over which are transmitted
messages, morbific or otherwise, as the case may be."27 The diagnosis of pelvic
abnormalities legitimized nervousness in women. The discovery of pathological
conditions, however slight, "proved" that the sufferer was not exaggerating or
imagining her ills but was justified in her complaints. Thus she earned through
biology the "right" to be sick that overworked middle-class men enjoyed.
G. Manly Ransom described a typical case of this kind in 1895:

Mrs. B-, Bridgeport, Conn., came to me December 20, 1892, having been a
confirmed neurasthenic for five years. I treated her for two weeks with warm douches
and massage. She returned to her home for the holidays, improved, and early in
January again placed herself in my care. She remained here nine weeks, steadily
gaining in strength and mental tone. As she was suffering from the effects of a
lacerated cervix, I performed hystero-trachelorrhaphy [suture ofthe lacerated cervix
uteri] assisted by Dr. J.F. McKernon, of this city. I will quote from her husband's
letter two months later: At the time my wife went under your care she had received
treatment at the hands of several specialists, and with little or no beneficial results
to her nervous system. I feared she had become a confirmed invalid, and organized
my household accordingly. It is now a little more than two months since she left
you. Gradually she has assumed her family cares and responsibilities. She seems
now quite like her former self, and has dispensed with the housekeeper.

J.H. Etheridge of Chicago reported a similar case in 1898 which further

demonstrates the belief that women could become neurasthenic as a result of
pathological conditions of the reproductive system:
Married woman, had been confined five and three years before. From being a strong,
self-reliant woman, who could do and endure anything, she presented a condition
of general hyperesthesia and such an intolerance of noises that her children nearly
drove her distracted. Her mental condition had become a source of gravest alarm
to her family and friends. These were the chief symptoms of her neurasthenic
condition-There were moderate lacerations of the cervix and about four-fifths
of the perinaeal body were absent. Six months after the necessary operations were
performed, she had fully regained her health of body and mind in every particular.29

While there was disagreement as to whether pathological gynecological

conditions were the cause or the result of neurasthenia, most physicians agreed
that a strong relationship existed between woman's anatomy and her nervous
system. The result of this view, of course, was that much attention was paid to
the female reproductive apparatus in the physical treatment of neurasthenia.
Repairs of lacerated cervixes and perineums were the most common treatments
employed by gynecological surgeons, although ovariotomies and even

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260 journal of social history

hysterectomies were performed when apparent pathological conditions were found

during what was essentially exploratory surgery.
Such drastic operations as ovariotomies and clitoridectomies have attracted
the attention of some historians who have suggested that conspiracy and control
were behind much of the gynecological surgery performed on nervous women
during the late Victorian period. In the neurasthenic literature, it seems that
other forces ? notably physicians' desires to specialize and desperate patients'
demands that doctors recognize their complaints as justifiable and "do something"
to relieve their symptoms ? accounted in large part for the spate of surgical
procedures employed in cases of nervousness. True, much female surgery, and
doubtless much unnecessary surgery, was performed by physicians who believed
that woman's nervous system depended upon her biology. But it is quite likely
that women themselves, and especially women who visited physicians for nervous
complaints, believed likewise. As T. Griswold Comstock, a St. Louis homeopath,
reported in 1892, nervous women often expected and even demanded surgical
treatment:

Neurasthenic patients are especially liable to fancy that they have some organic
disease of the uterus or ovary, and that the operation of laparotomy will have to
be made upon them before they can find permanent relief. They are fully impressed
with this idea, and think no other treatment will reach their case. They are willing
to undergo this grave operation, and insist that it must be made, and instance some
other person of their acquaintance who was thus treated and cured. Quite recently
I had such a case, where a careful physical examination elicited the existence of
no organic disease of the womb or ovary, but she was willing to have her ovaries
removed. This lady was highly educated, and all of her troubles could be directly
traced to mental emotions, hysteria, and melancholy. ?

Regina Markell Morantz, in a self-described "cursory investigation," has also

challenged the view that Victorian gynecology constituted an attack on female
sexuality. Not only were clitoridectomies, ovariotomies, and hysterectomies
performed less often than Barker-Benfield asserts, she found, but they were
reserved almost entirely for cases involving cancer, puerperal fever, and other
conditions likely to provoke desperate remedies.31 In the case of neurasthenic
women, surgery was primarily limited to restorative measures to repair the perineal
tears and lesions that frequently accompanied childbirth. And, in fact, those
most likely to be described in derogatory tones by physicians ? never-married
and childless middle-class women ? were those least likely to be operated upon.
Further evidence that Victorian gynecology was not particularly harsh in
comparison with other therapeutics of the period is found in the treatment of
some males diagnosed as sexual neurasthenics. The treatment of these patients
was frequently bold, if not draconian.32 In addition to special diets, instruction
in hygiene, and warnings against bad thoughts and habits, physicians often applied
local treatments directly to the genitals of male patients. WT. Elam of St. Joseph,
Missouri, cited the following list of treatments: "dividing and stretching strictures
with irrigations from time to time, topical applications through the endoscope
to infiltrated granular and excoriated areas, deep instillations, prostatectomy,
vasectomy, prostatotomy (Bottini) circumcision and dissecting up adherent
foreskin, etc."33 The passing of sounds to stretch even minor strictures and hence

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THE RIGHT TO BE SICK 261

"relieve congestion" was especially popular. As H.B. Combs of Bastrop, Texas,

described his procedure: "I... instill every two or three days a 2 per cent solution
of aristol and europhen oil..., first passing a large-sized steel sound and letting
it remain in the urethra ten minutes. I rarely have to make more than six or
seven... instillations, though sometimes have patient pass the steel sound weekly
for two or three months"34
Physicians who treated male neurasthenics by such painful measures as dividing
minor strictures and passing sounds through urethras believed that they were
putting neurasthenia on a more scientific basis. Rather than dismissing their
patients' complaints as imaginary or, worse, as degeneracy, they assumed that a
physical, i.e., "adequate" cause existed that explained these patients' sufferings.
Just as gynecologists held that many female neurasthenics' complaints were due
to disturbances of the reproductive apparatus, so genito-urinary surgeons claimed
that underlying physical causes were present in their male (and usually middle-
class) patients. As Bransford Lewis of St. Joseph, Missouri, observed in 1890:

Formerly all the backaches, the head pains, the peculiar sensations, insomnia, etc,
in women were interpreted as being but manifestations of that ubiquitous malady,
hysteria. That was the fashion a half century ago. Now no one would think of
pronouncing any such case to be hysteria until a thorough and complete examination
of the uro-genital system had been made; and even then he would be very chary
about making such a diagnosis pure and simple, for fear that some more acute
observer might come across the patient and discover the hidden secret of the disease.
The influence of the ovaries, uterus, tubes, and other pelvic organs of woman on
her general condition, both mental and physical, is becoming better understood
every day, and we now hear less of hysteria and more of distinct pathological changes
in those organs.... Observation has taught me, that where a man is making the
complaint, instead of a woman, there are just as good grounds for suspecting some
tangible basis for such a complaint as there are in the woman detailing the symptoms
mentioned.

Around the turn of the century urinary surgeons began to press their case
that so-called sexual neurasthenia was often more properly diagnosed as urethritis
or other such condition. Eugene Fuller, professor of venereal and genito-urinary
surgery at the New York Post-Graduate Medical School, raised this issue in an
1898 address to the section of neurology ofthe New York Academy of Medicine:
"I take the liberty of suggesting," he remarked, "that a goodly proportion of the
males who think themselves afflicted with sexual neurasthenia are in reality
suffering from inflammatory disease of their sexual apparatus, their nervous
symptoms being simply reflected from and dependent on such inflammation."36
Four years later WT. Elam noted that "some of the prominent writers of to-day
are seeking, and we think rightly so, to place this form of neurasthenia upon
a purely histopathological, instead of psychopathological, basis, or an indefinite
combination of the two."37
These physicians argued that nervous symptoms in males could result from
abnormalities of the genito-urinary tract, just as gynecologists held that disorders
of the reproductive apparatus frequently produced neurasthenia in women.
Pathological conditions might be caused by abuse of the sexual organs, but could
also arise independently, thus absolving victims of the guilt which had previously

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262 journal of social history

been associated with sexual neurasthenia. This argument provided a rational

explanation for nervousness and sexual dysfunction in men; physicians could
therefore avoid branding such patients as either degenerates or hypochondriacs.
The belief in a histopathological basis of sexual symptoms in men, though it
resulted in rather drastic treatments that in some ways resembled those used by
gynecologists, provided middle-class male sexual neurasthenics with a guiltless
"right to be sick."
The theory of a physical basis of sexual neurasthenia was also attractive to
genito-urinary surgeons because it promised to enhance their specialty. Ramon
Guiteras, a New York urinary surgeon, noted in 1901 that
the recognition of the important role played by lesions of the genital tract in the
production of all sorts of morbid conditions in women has done more than anything
else to raise gynecology to the dignity of a specialty. Is it not absurd, then, to allow
a faulty classification of neurasthenia to mask the importance of such lesions in
the male in the causation of seemingly remote and disproportionate systemic
disturbances? By ceasing to limit the application of the term sexual neurasthenia
to those cases which show prominent sexual symptoms, and extending it to include
all those cases of neurasthenia in which lesions of the genital tract are found to
be the source of the trouble, we shall not only be putting the use of the term upon
a rational foundation, but we shall tend to secure a proper recognition of the far-
reaching systemic effects of genital lesions in the male; and emphasize the necessity
of a thorough examination of the genital tract in all cases of neurasthenia.
Thus Guiteras clearly suggested that nervous symptoms in men could be caused
by undetected disturbances of the genital tract ? the same argument that was
used to justify gynecological surgery for nervous women ? and that the successful
treatment of such cases would do much to advance the genito-urinary specialty.
Charles E. Lockwood of New Y)rk reported a case in 1894 that illustrates the
result that could be achieved when both physician and patient subscribed to
the theory of a connection between the male sexual apparatus and nervous system:

E.T.R., .. .consuited me December 19, 1891-In October, 1892, he began to feel

a slight irritation something like a sensation of heat, in the head of the penis, and
thinks he had a slight gleety discharge at that time. He also noticed that the urethia
did not empty itself completely.... He also had a feeling of weakness in the forearms,
hands, and fingers, and slight pain in one foot.. . . Complains that his brain is
muddled after sexual intercourse; that he has queer feeling in his hips, which he
decribes as pain, weight, and bearing down.. . . An examination of his urethra
showed stricture admitting No. 17 bulb, American scale, an eighth ofan inch from
the meatus urinarius. The stricture was incised freely so as to admit No. 22 bulb... .
January 3, 1893. ? Passed No. 22 short sound through the meatus, and No. 15
sound into the bladder. Patient home, having been instructed to pass No. 22 or
No. 18 conical short sound through the meatus every fourth day, for a week, and
once a week thereafter for a month. March 12th. ? Patient writes me from his
home that he has gained twenty-five pounds since the operation, and that all his
unpleasant symptoms have disappeared. It seems to be of interest to note in this
case the annoying train of nervous symptoms produced by a slight stricture of the
meatus urinarius, and their complete and permanent removal by free division of
the stricture and subsequent dilatation during the process of healing.
It seems clear that the eagerness with which both gynecological and urinary
surgeons perceived linkages between nervous disorders and the reproductive

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THE RIGHT TO BE SICK 263

systems of men and women were at least as closely related to their professional
aspirations as to their personal biases. Both groups recognized that acceptance
of a physical basis for mental disturbance promised to enlarge their respective
specialties. It was in the late-nineteenth century that the first important medical
subspecialties arose, and it was increasingly apparent that those physicians
identified as specialists enjoyed higher incomes and greater prestige than did
general practitioners. It is not surprising, then, that the relatively well-established
gynecological specialists were determined to expand the boundaries of their field,
nor that the newer genito-urinary specialists were anxious to follow suit.40
These theories were generally as attractive to nervous patients as they were
to medical specialists. The discovery of a pathological condition was more
appealing than most other possible causes of nervousness, including degeneracy,
hysteria, and hypochondria. Thus most neurasthenics were provided with a
justifiable "right to be sick" (physical cause) if not a praiseworthy one (overwork).
It appears that lower-class men, who were unlikely to visit specialists, were the
only nervous patients excluded from the legitimization of nervousness. Poor males,
who most often visited dispensaries or general practitioners at best and irregular
practitioners or quacks at worst, continued to be labeled as degenerates or at
least as weak-willed by their physicians.
The evidence considered here suggests that nervous patients in the late
Victorian era, despite the similarity of their symptoms, had very different
experiences in seeking medical treatment. Among the most important factors
accounting for these differences were patient gender and class, as well as physician
specialty. It is highly probable that physicians' diagnoses of nervousness were based
on their innate beliefs in social stereotypes ofthe passionless woman, the aspiring
middle-class man, and the unbridled lower-class male, and that their questioning
of patients unconsciously elicited the expected responses. (It appears, for example,
that women were seldom questioned about their sexual habits or desires, thus
reinforcing the stereotype of the "chaste" female.) Neurasthenic patients were
evidently desperate enough to seek treatment and appeared sincere enough to
avoid being diagnosed as hypochondriacal. They were likely, then, to accept
diagnoses implying biological predisposition or even degeneracy in order to gain
access to treatment, and to submit to rather drastic remedies in their search for
mental harmony.
This evidence, of course, carries significant implications for analyses of
doctor/patient relationships in other diseases and other times. While case records
tell us more about physicians' perceptions than they do about patient behavior,
physicians' attitudes are important in the realm of what Estelle Freedman has
called "sexual politics" ? the attempts of culturally dominant groups to impress
their own sex-linked values on the less powerful.41 The field of "class politics"
in health care is also a fertile one, and the interaction of both elements seems
especially promising. This study thus demonstrates the necessity of examining
diverse patient and physician populations in attempting to assess the relative
importance of various elements of doctor-patient interactions. Comparative studies
of groups large enough to yield substantive evidence will doubtless give historians
increasing confidence to generalize about the effects of physician attitudes on
medical practice and on the transmission of social values.

University of Texas RG. Gosling

San Antonio, Texas 78285 Joyce M. Ray

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264 journal of social history

FOOTNOTES

The authors wish to thank Don Doyle and Linda Pritchard for their advice and suggestions.

1. The recent scholarship of American Victorianism is cited in Mary P. Ryan, "The Explosion
of Family History" Reviewsin American History 10 (1982): 181-95, and in Estelle B. Freedman,
"Sexualityin Nineteenth-Century America: Behavior,Ideology, and Politics"Reviewsin American
History 10 (1982): 196-215. Several recent studies have attacked the stereotype of female
passionlessness which has dominated the literature of Victorianism for some time. For an
essay which assesses the current state of this dispute, see Carol Zisowitz Stearns and Peter
N. Stearns, "Victorian Sexuality: Can Historians Do It Better?"Journalof Social History 18
(1985): 625-34.

2. See Charles E. Rosenberg and Carroll Smith-Rosenberg, "The Female Animal: Medical
and Biological Views of Women,"Journalof American History60 (1973): 332-56, John S. and
Robin M. Haller, The Physicianand Sexuality in VictorianAmerica (Urbana, 1974), and Anita
Clair and Michael Fellman, Making Sense of Self: Medical Advice Literaturein Late Nineteenth-
CenturyAmerica (Philadelphia, 1981).

3. GJ. Barker-Benfield, The Horrorsof the Half-KnownLife: Male Attitudes TowardWomenand

Sexuality in Nineteenth-CenturyAmerica (New York, 1976).

4. Barbara Ehrenreich and Deirdre English, Complaints and Disorders:The Sexual Politicsof
Sickness(Old Westbury, 1973).

5. Estelle Freedman notes this tendency in "Sexuality in Nineteenth-Century America,"209.

6. Data for this article were derived from F.G. Gosling, Before Freud:Neurasthenia and the
AmericanMedical Community,1870-1910,forthcoming, University of Illinois Press. BeforeFreud
is a book-length study which includes a collective biography of the physicians who wrote
on neurasthenia, content analysis o{ the journal literature on the disease, and examination
o{ the case records of individuals diagnosed as neurasthenic in the years 1870-1910. For this
article the authors have taken a subset of the patient population to examine in more detail
the effect of class and gender ? and physician specialty ? on the diagnosis and treatment
of neurasthenics. The 1885-1910 period encompassed the largest group of nervous patients
treated by a broad cross-section of the American medical profession.

7. Between 1885 and 1910physicians reported neurasthenics at twice the rate they had between
1870 and 1885. Two hundred and thirty-seven ofthe 307 patients (77%)described in the medical
journal literaturebetween 1870 and 1910were reported in the last twenty-five years ofthe period.

8. George M. Beard, American Nervousness,Its Causes and Consequences(New York, 1881). A

complete list of Beard'snumerous publications can be obtained by combining citations given
in the Dictionaryof AmericanBiographywith those provided in several ofthe footnotes in Philip
P. Wiener, "G.M. Beard and Freud on American Nervousness,'" Journalof the Historyof Ideas
17 (1956): 269-74. The most useful articles on Beard are Charles Rosenberg, "The Place of
George M. Beardin Nineteenth-Century Psychiatry"Bulletinofthe Historyof Medicine36 (1962):
245-59, and Barbara Sicherman, "The Paradox of Prudence: Mental Health in the Gilded
Age,"Journalof American History61 (1976): 890-912. Other historians have dealt incidentally
with Beard and/or neurasthenia in the course of their work on various aspects of the history
of psychiatry and neurology in the Gilded Age. Among them are Sy R Fullinwider,
"Neurasthenia: The Genteel Caste's Journey Inward,"RockyMountain Social ScienceQuarterly
2 (1974): 1-9,John S. and Robin M. Haller, The Physicianand Sexuality,5-43, Sicherman, "The
Uses of a Diagnosis: Doctors, Patients, and Neurasthenia," Journalof the Historyof Medicine.
32 (1977): 33-54, M.B. Macmillan, "Beard'sConcept of Neurasthenia and Freud's Concept
ofthe Actual Neuroses,"Journalofthe Historyofthe BehavioralSciences12 (1976): 376-90, James
B. Gilbert, WorkWithout Salvation: America'sIntellectualsand IndustrialAlienation, 1880-1910

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THE RIGHT TO BE SICK 265

(Baltimore, 1977), 31-43, and Nathan G. Hale, Jr., Freudand the Americans:The Beginningsof
Psychoanalysisin the United States, 18764917 (New York, 1971), 63-7.

9. The case records were located by compiling a comprehensive list of articles on neurasthenia
from IndexMedicus, Series I, volumes 7-21 (1885-1899), and Series II, volumes 1-8 (1903-1910),
Office, United States Army, second
and the lndex Catalog of the Libraryof the Surgeon-GeneraVs
series, volume 11 (1906), and third series, volume 9 (1929).

10. As their articles on the disease make clear, physicians diagnosed far more than two hundred
and thirty-two neurasthenics between 1885-1910,but in many instances they generalized about
their experiences with neurasthenics as a group and did not give the details of individual
cases. The generalizations on class and gender contained in articles of this type did not differ
significantly from those presented in individual case records.

11. The sixty-one physicians who reported these one hundred and sixty-seven cases also
represented a full spectrum of types, from prestigious urban neurologists to rural general
practitioners about whom little personal information is known. Gynecologists, insane asylum
superintendents, and even oculists and ophthalmologists competed with neurologists for the
right to treat nervous patients, as did homeopaths, eclectics, and other "irregular"practitioners.
With the exception that all but two of the authors were men, little is predictable about the
physicians who treated neurasthenia. Almost half (47%) lived in cities of over 500,000, but
more than a quarter (27%) resided in communities of less than 50,000, and fifteen percent
represented towns with fewer than 10,000 people. This distribution refutes the traditional
historical view of neurasthenia as the exclusive province of elite urban neurologists and suggests
that the attitudes expressed by these authors represent the views of a wide range of physicians.

12. These class groupings follow George Beard'sdistinction between brain-workersand muscle-
workers. Brain-workerswere usually private, paying patients who were professionals or at least
held such white-collar positions as bank teller or clerk. Women were assumed to be in this
class if they visited a private physician and were described as "housewife,"or by a more revealing
term such as "wife of financier." Muscie-workers were lower-class patients often treated in
dispensaries or outpatient clinics because they could not afford private care.

13. E.C. Kinney, "Nervousness,"Proceedingsofthe ConnecticutState Medical Society 1885: 28-9.

14. C.W.Hitchcock, "BorderLine Cases of Neurasthenia,"Journalof the MichiganState Medical

Society 5 (1906): 587.

15. F.S. Smith, "Neurasthenia, With Report of Cases," Medical Age 18 (1900): 732.

16. Edward C. Hornibrook, "Neurasthenia" Transactionsof the Iowa Medical Society 9 (1892):
117-18.

17. When physicians writing on neurasthenia used the term heredity, they did not, of course,
define it solely in terms of genetic inheritance. While they recognized that individuals inherited
their mental predispositions, most physicians subscribed to a crude Lamarckianism and held
that people could overcome all but the most odious inherited characteristicsthrough will power,
and could even pass on acquired characteristics to their children. This almost instinctual
rejection of biological determinism was complicated by physicians' equally instinctual class
biases. Like other middle class spokesmen in the period, physicians believed that the upper
classes were evolutionally more advanced than the ignorant poor. The cultured classes were
capable of finer sensibilities, though this in turn made them more susceptible to emotional
stress than members of the less evolved lower orders, and thus more prone to attacks of
neurasthenia.

18. MargaretA. Cleaves, "Franklinization as a Therapeutic Measure in Neurasthenia,"Journal

of the American Medical Association 27 (1896): 1049-052.

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266 journal of social history

19. F.B. Bishop, "Sexual Neurasthena As It Stands in Relation to the Border-Landof Insanity,
and Insanity in General,"VirginiaMedicalMonthly18 (1891-2):754. Bishop, like many physicians,
probably associated sexual excess with insanity because of observed cases of general paresis
and insanity caused by syphilis.

20. The diagnosis of sexual neurasthenia was not confined to poor males and was in fact
associated with youth even more strongly than with social class. The average age o{ men
diagnosed as sexual neurasthenics was only thirty, compared with thirty-six among all male
neurasthenics. Nevertheless, lower-class males were almost twice as likely (41%,compared with
20%) to be diagnosed as sexual neurasthenics than were middle-class men. The difference
in mean age between lower-class men (35) and middle-class men (38) fails to account for this
phenomenon. Clearly physicians' class views were the determining factor.

21. J.A. Holloway, "Sexual Neurasthenia," Texas Medical News 12 (1902-03): 53.

22. Henry B. Deale and S.S. Adams, "Neurasthenia in Young Women,"American Journalof
Obstetrics29 (1894): 191.

23. J.P.C.Foster, "Suggestive and Hypnotic Treatment of Neurasthenia " Yale Medical Journal
8 (1901-2): 18-19.

24. Lincoln Gray Taylor,"Some Unrecognized Forms of Neurasthenia" Medical Brief35 (1907):
358.

25. Henry E. Leake, "Neurasthenia in Relation to the Abdominal Diseases of Women,"Texas

Medical Journal 18 (1902-3): 408.

26. ED. Bain, "Nervous Prostration" Transactionsofthe Ohio State Medical Society(1897): 246-7.

27. Charles A. Reed, "The Genital Factor in Certain Cases of Neurasthenia in Women,"
Gaillard'sMedical Journal 70 (1899): 68.

28. G. Manly Ransom, "Neurasthenia; Its Cure by Thermotherapy,"Medical Record47 (1895):

366.

29. J.H. Etheridge, "The Relations Between Some Perinaeal Lacerations and the Neurasthenic
State," The American Gynaecologicaland ObstetricalJournal 12 (1893): 142-3.

of the American
30. T. Griswold Comstock, "Neurasthenia and Reference to Cases,"Transactions
Instituteof Homeopathy45 (1892): 292.

31. Regina Markell Morantz, review of Barker-Benfield, The Horrorsof the Half-Hidden World,
in Bulletin of the History of Medicine 51 (1977): 20740.

32. For a more detailed discussion of medical treatments for the sexual problems of men during
the period see Gail Pat Parsons, "Equal Treatment for All: American Medical Remedies for
Male Sexual Problems, 1850-1900,"Journal of the History of Medicine 31 (1977): 55-71.

33. WT. Elam, "Sexual Neurasthenia in the Male," Transactionsof the Medical Association of
Missouri 45 (1902): 261.

34. H.B. Combs, "Sexual Neurasthenia Resulting from Posterior Urethritis," Transactionsof
the Texas Medical Association 36 (1904): 361.

35. BransfordLewis, "A Consideration of Sexual Neurasthenia,"AmericanPractitionerand News

9 (1890): 229.

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THE RIGHT TO BE SICK 267

36. Eugene Fuller, "Is Sexual Neurasthenia in the Male As Frequent As Is Commonly
Supposed?" Medical Record53 (1898): 187.

37. Elam, "Sexual Neurasthenia in the Male," 257.

38. Ramon Guiteras, "Sexual Neurasthenia in the Male; A Plea For a More Accurate Use
of the Term;Treatment of the True Form with Citation of Cases,"Medical News 79 (1901): 54.

39. Charles E. Lockwood, "Interesting Cases from General Practice Illustrating Special Points
of Treatment,"New YorkMedical Journal 60 (1894): 749.

40. The American Gynecological Society was founded in 1876, the American Association
of Genito-Urinary Surgeons in 1886.

41. Freedman, "Sexuality in Nineteenth-Century America," 205-9.

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