Bodily Subjects: Essays on Gender and Health, 1800-2000 9780773544147

Table of contents :
Cover
......Page 1
McGill-Queen’s/Associated Medical Services Studies in the History of Medicine, Health, and Society......Page 3
Title......Page 6
Copyright......Page 7
Contents......Page 8
Acknowledgments......Page 10
Introduction......Page 14
Section One Embodied Citizenship......Page 34
1 The “Bone and Sinew of the Nation”: Antebellum Workingmen on Health and Sovereignty......Page 36
2 Gendered Roles, Gendered Welfare: Health and the English Poor Law, 1871–1911......Page 64
3 Constructing Hygienic Subjects: The Regulation and Reformation of Aboriginal Bodies......Page 85
4 Shaping Student Bodies and Minds: The Redefinition of Self at English-Canadian Universities, 1900–60......Page 111
Section Two Defining and Contesting Illness......Page 132
5 Osteomalacia: Femininity and the “Softening of Bones” in Central European Medicine (1830–1920)......Page 134
6 Disciplining Male Bodies: Infertility and Medicine in Germany in the Decades after the Second World War......Page 163
7 “Cherishing Hopes of the Impossible”: Mothers, Fathers, and Disability at Birth in Mid-Twentieth-Century New Zealand......Page 189
8 Breaking Down Barriers: Women in the Ontario HIV/AIDS Movement before the Advent of Antiretroviral Therapy......Page 211
Section Three Authority and Ideals......Page 236
9 Referred for Special Services: Children, Youth, and the Production of Heteronormativity at Alexandra Neighbourhood House in Post-war Vancouver......Page 238
10 The Heterosexual Nature of Health and Hygiene Advertisements in the Cold War Era......Page 256
11 Educating Doctors about Obesity: The Gendered Use of Pharmaceutical Advertisements......Page 279
12 Motherhood Gone Mad? The Rise of Postpartum Depression in the United States during the 1980s......Page 314
13 From Fixing to Enhancing Bodies: Shifting Ideals of Health and Gender in the Medical Discourse on Cosmetic Surgery in Twentieth-Century Canada......Page 330
Bibliography......Page 358
Contributors......Page 392
Index......Page 396

Citation preview

b o d i ly s u b j e c t s

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McGill-Queen’s/Associated Medical Services Studies in the History of Medicine, Health, and Society Series Editors: S.O. Freedman and J.T.H. Connor Volumes in this series have financial support from Associated Medical Services, Inc. (A M S ). Associated Medical Services Inc. was established in 1936 by Dr Jason Hannah as a pioneer prepaid notfor-profit health care organization in Ontario. With the advent of medicare, A M S became a charitable organization supporting innovations in academic medicine and health services, specifically the history of medicine and health care, as well as innovations in health professional education and bioethics.

2 A Long Way from Home The Tuberculosis Epidemic among the Inuit Pat Sandiford Grygier

7 A Young Man’s Benefit The Independent Order of Odd Fellows and Sickness Insurance in the United States and Canada, 1860–1929 George Emery and J.C. Herbert Emery

3 Labrador Odyssey The Journal and Photographs of Eliot Curwen on the Second Voyage of Wilfred Grenfell, 1893 Ronald Rompkey

8 The Weariness, the Fever, and the Fret The Campaign against Tuberculosis in Canada, 1900–1950 Katherine McCuaig

4 Architecture in the Family Way Doctors, Houses, and Women, 1870–1900 Annmarie Adams

9 The War Diary of Clare Gass, 1915–1918 Edited by Susan Mann

1 Home Medicine The Newfoundland Experience John K. Crellin

5 Local Hospitals in Ancien Régime France Rationalization, Resistance, Renewal, 1530–1789 Daniel Hickey 6 Foisted upon the Government? State Responsibilities, Family Obligations, and the Care of the Dependent Aged in NineteenthCentury Ontario Edgar-André Montigny

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10 Committed to the State Asylum Insanity and Society in NineteenthCentury Quebec and Ontario James E. Moran 11 Jessie Luther at the Grenfell Mission Edited by Ronald Rompkey 12 Negotiating Disease Power and Cancer Care, 1900–1950 Barbara Clow

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13 For Patients of Moderate Means A Social History of the Voluntary Public General Hospital in Canada, 1890–1950 David Gagan and Rosemary Gagan 14 Into the House of Old A History of Residential Care in British Columbia Megan J. Davies 15 St Mary’s The History of a London Teaching Hospital E.A. Heaman 16 Women, Health, and Nation Canada and the United States since 1945 Edited by Georgina Feldberg, Molly Ladd-Taylor, Alison Li, and Kathryn McPherson 17 The Labrador Memoir of Dr Henry Paddon, 1912–1938 Edited by Ronald Rompkey 18 J.B. Collip and the Development of Medical Research in Canada Extracts and Enterprise Alison Li 19 The Ontario Cancer Institute Successes and Reverses at Sherbourne Street E.A. McCulloch 20 Island Doctor John Mackieson and Medicine in Nineteenth-Century Prince Edward Island David A.E. Shephard

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21 The Struggle to Serve A History of the Moncton Hospital, 1895 to 1953 W.G. Godfrey 22 An Element of Hope Radium and the Response to Cancer in Canada, 1900–1940 Charles Hayter 23 Labour in the Laboratory Medical Laboratory Workers in the Maritimes, 1900–1950 Peter L. Twohig 24 Rockefeller Foundation Funding and Medical Education in Toronto, Montreal, and Halifax Marianne P. Fedunkiw 25 Push! The Struggle for Midwifery in Ontario Ivy Lynn Bourgeault 26 Mental Health and Canadian Society Historical Perspectives Edited by James Moran and David Wright 27 SARS in Context Memory, History, and Policy Edited by Jacalyn Duffin and Arthur Sweetman 28 Lyndhurst Canada’s First Rehabilitation Centre for People with Spinal Cord Injuries, 1945–1998 Geoffrey Reaume 29 J. Wendell Macleod Saskatchewan’s “Red Dean” Louis Horlick

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30 Who Killed the Queen? The Story of a Community Hospital and How to Fix Public Health Care Holly Dressel

37 Infection of the Innocents Wet Nurses, Infants, and Syphilis in France, 1780–1900 Joan Sherwood

31 Healing the World’s Children Interdisciplinary Perspectives on Health in the Twentieth Century Edited by Cynthia Comacchio, Janet Golden, and George Weisz

38 The Fluorspar Mines of Newfoundland Their History and the Epidemic of Radiation Lung Cancer John R. Martin

32 A Canadian Surgeon in the Army of the Potomac Francis M. Wafer Edited by Cheryl A. Wells

39 Small Matters Canadian Children in Sickness and Health, 1900–1940 Mona Gleason

33 A Sadly Troubled History The Meanings of Suicide in the Modern Age John Weaver

40 Sorrows of a Century Interpreting Suicide in New Zealand, 1900–2000 John C. Weaver

34 SARS Unmasked Risk Communication of Pandemics and Influenza in Canada Michael G. Tyshenko with assistance from Cathy Patterson

41 The Black Doctors of Colonial Lima Science, Race, and Writing in Colonial and Early Republican Peru José R. Jouve Martín

35 Tuberculosis Then and Now Perspectives on the History of an Infectious Disease Edited by Flurin Condrau and Michael Worboys

42 Bodily Subjects Essays on Gender and Health, 1800–2000 Edited by Tracy Penny Light, Barbara Brookes, and Wendy Mitchinson

36 Caregiving on the Periphery Historical Perspectives on Nursing and Midwifery in Canada Edited by Myra Rutherdale

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Bodily Subjects Essays on Gender and Health, 1800–2000

edited by

Tracy Penny Light, Barbara Brookes, and Wendy Mitchinson

McGill-Queen’s University Press Montreal & Kingston • London • Ithaca

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©  McGill-Queen’s University Press 2014 ISBN ISBN ISBN ISBN

978-0-7735-4414-7 (cloth) 978-0-7735-4415-4 (paper) 978-0-7735-9641-2 (eP DF ) 978-0-7735-9642-9 (eP UB)

Legal deposit fourth quarter 2014 Bibliothèque nationale du Québec Printed in Canada on acid-free paper that is 100% ancient forest free (100% post-consumer recycled), processed chlorine free This book has been published with the help of a grant from the Canadian Federation for the Humanities and Social Sciences, through the Awards to Scholarly Publications Program, using funds provided by the Social Sciences and Humanities Research Council of Canada. McGill-Queen’s University Press acknowledges the support of the Canada Council for the Arts for our publishing program. We also acknowledge the financial support of the Government of Canada through the Canada Book Fund for our publishing activities.

Library and Archives Canada Cataloguing in Publication Bodily subjects: essays on gender and health, 1800–2000 / edited by Tracy Penny Light, Barbara Brookes, and Wendy Mitchinson. (McGill-Queen’s / Associated Medical Services studies in the history of medicine, health, and society; 42) Includes bibliographical references and index. Issued in print and electronic formats. ISB N 978-0-7735-4414-7 (bound). – I S BN 978-0-7735-4415-4 (pbk.). – ISB N 978-0-7735-9641-2 (eP DF ). – I S BN 978-0-7735-9642-9 (eP D F) 1. Women – Health and hygiene – History.  2. Men – Health and hygiene – History.  3. Femininity – Health aspects – History.  4. Masculinity – Health aspects – History.  5. Health – Sex differences – History.  I. Penny Light, Tracy, 1970–, author, editor  II. Brookes, Barbara L. (Barbara Lesley), 1955–, author, editor  III. Mitchinson, Wendy, author, editor  IV. Series: McGill-Queen’s / Associated Medical Services studies in the history of medicine, health, and society; 42 ra564.85.b63 2014

613'.0424

c 2014-905960-4 c 2014-905961-2

This book was typeset by Interscript in 10.5/13 Baskerville.

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Contents

   Acknowledgments  ix    Introduction  3 Barbara Brookes, Wendy Mitchinson, Tracy Penny Light S e c t i o n O n e   E m b o d i e d C i t i z e n s h i p   23   1 The “Bone and Sinew of the Nation”: Antebellum Workingmen on Health and Sovereignty  25 Patricia A. Reeve   2 Gendered Roles, Gendered Welfare: Health and the English Poor Law, 1871–1911  53 Marjorie Levine-Clark   3 Constructing Hygienic Subjects: The Regulation and Reformation of Aboriginal Bodies  74 Meg Parsons   4 Shaping Student Bodies and Minds: The Redefinition of Self at English-Canadian Universities, 1900–60  100 Catherine Gidney Section two 

D e f i n i n g a n d C o n t e s t i n g I l l n e s s   121

  5 Osteomalacia: Femininity and the “Softening of Bones” in Central European Medicine (1830–1920)  123 Brigitte Fuchs   6 Disciplining Male Bodies: Infertility and Medicine in Germany in the Decades after the Second World War 152 Antje Kampf

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viii Contents

  7 “Cherishing Hopes of the Impossible”: Mothers, Fathers, and Disability at Birth in Mid-Twentieth-Century New Zealand  178 Barbara Brookes   8 Breaking Down Barriers: Women in the Ontario H I V / A I D S Movement before the Advent of Antiretroviral Therapy 200 Natalie L. Gravelle S e c t i o n T h r e e   A u t h o r i t y a n d I d e a l s   225   9 Referred for Special Services: Children, Youth, and the Production of Heteronormativity at Alexandra Neighbourhood House in Post-war Vancouver  227 Anika Stafford and Mona Gleason 10 The Heterosexual Nature of Health and Hygiene Advertisements in the Cold War Era  245 Thomas Wendelboe 11 Educating Doctors about Obesity: The Gendered Use of Pharmaceutical Advertisements  268 Wendy Mitchinson 12 Motherhood Gone Mad? The Rise of Postpartum Depression in the United States during the 1980s  303 Rebecca Godderis 13 From Fixing to Enhancing Bodies: Shifting Ideals of Health and Gender in the Medical Discourse on Cosmetic Surgery in Twentieth-Century Canada  319 Tracy Penny Light    Bibliography  347    Contributors  381    Index  385

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Acknowledgments

The idea for this book originated in a conversation between Tracy Penny Light and Eileen O’Connor at a meeting of the Canadian Society for the History of Medicine. Later, plans for this book unfolded in conver­ sations between the three of us when Barbara Brookes visited the Uni­ versity of Waterloo in 2009. The plan would not have moved forward, however, without generous support from the Planning, Meetings and Dissemination fund of the Canadian Institutes for Health Research (C I H R ). Leslie Copp, associate director of Funding Agencies and NonProfit Sponsors at the Research Office of the University of Waterloo was instrumental in helping us to navigate the grant application process. We also are indebted to Myroslaw Tataryn, then the vice president academic and dean at St. Jerome’s University; Ken Coates, then dean of arts at the University of Waterloo; and Gary Bruce, chair of the History Department at Waterloo for their generous financial support. We also benefited from the support of the Canada Research Chair Program through the Canada Research Chair in Gender and History of Medicine at the University of  Waterloo and the Humanities Division of the University of Otago. ­Angela Roorda at the University of Waterloo provided helpful feedback on an early version of our grant application and Marlene Epp generously provided us with a copy of a successful application that she had written for another project as a model for ours. All of this support enabled us to invite international scholars to Waterloo for a tremendously productive workshop in May 2011. Instrumental to the success of the workshop was Dr. Emanuele Sica, who provided administrative and organizational support for the workshop. We also thank Heather Marshall and Alisha Pol who took notes and assisted with workshop planning and the Walper Hotel, Kitchener, for accommodation during our meeting.

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x Acknowledgments

Colleagues assisted in various ways along the way. We wish to extend our thanks to Alisha Pol and Caley McCarthy who were instrumental at various stages of the manuscript production – we appreciate your attention to detail. Donna Hayes, administrative assistant and administrative co-ordinator of graduate studies, Department of History, University of Waterloo, and Nancy Birss, secretary at the Department of History, both provided helpful assistance. Jonathan Crago at McGill-Queen’s University Press has been enormously supportive of the project from its inception and we thank him for his guidance along the way. We also thank Ryan Van Huijstee and Jessica Howarth at M Q U P for their assistance. The anonymous reviewers were rigorous, thoughtful, and generous. Their feedback strengthened the collection and their support of it was critical. We also benefitted from the editing prowess of Camilla Blakely and Jennifer Thomas. Of course, this book would not have been a possibility if not for the thoughtful and engaging work of our contributors. Thank you for your enthusiasm and commitment to this endeavour. Finally, our families have supported us throughout this process, and we want to acknowledge them here for all the quiet and thoughtful ways they make our work possible.

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b o d i ly s u b j e c t s

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Introduction B a r ba r a B r o o k e s , W e n dy Mitchinson, Tracy Penny Light

Constant good health is a chimera: the thing we all want, don’t notice when we have it, and mourn when we lose it. Being “healthy” is also something that women and men “do” in different ways.1 The authors in  Bodily Subjects all explore the historical entanglement between ­gender and health to expose how women and men “did” health in a variety of  locations, from the nineteenth-century English Poor Law Union of Stourbridge, an early twentieth-century Aboriginal reserve in Queensland, Australia, to A I D S activists on the streets of Toronto in the 1990s. Our volume takes as its subject how gender is integral to the understanding of health and the way its meaning is embedded in cultural contexts connected to place and time. Our title reflects the way in which the body is both a subject of inquiry and a phenomenological experience. There is no “I” without a body and that body, Foucault has argued, is subject to regimes of power.2 The title, Bodily Subjects, then, should be read in two ways. First, it refers to the embodied meanings of health for men and women and how these have expanded over time, from an able body signifying health in the nineteenth century to concepts of “well-being,” a psychological ­interpretation, which came to dominate health discourse in Western countries by the late twentieth century. Second, it refers to the way in which ill health turns individuals into subjects of the medical gaze. Medical expertise is brought to bear in diagnosing and treating individuals in ways that are seen through the lens of gender. The arc of this collection proceeds through a series of site-specific case studies to demonstrate the way health is refracted by gender and how “health” itself is open to a myriad of interpretations determined by

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4  Bodily Subjects

class, race, ability, and expertise. By demonstrating how these interpretations are chronologically and geographically specific, our intention is to promote further research on gender and health. Taken together, the essays in this volume address the multiple meanings of health over time and place. Health has too often become a concept whose meanings we assume to understand. Historical case studies suggest the way definitions of health are saturated in cultural meaning. Health, therefore, has been defined by the ability to look or act in whatever way was considered normal; in turn, normal was almost always gendered. The topics of health and gender have generated a vast range of scholarship from authors in a multitude of disciplines but only rarely have they been considered together. Women’s health and women in the health professions have been the focus of two major collections, Judith Walzer Leavitt’s Women and Health in America (1984) and Rima Apple’s Women, Health, and Medicine in America (1990). These collections were preceded by Edward Shorter’s A History of Women’s Bodies (1982) and succeeded by a number of significant studies such as Ornella Moscucci’s The Science of Woman: Gynaecology and Gender in England 1800–1929 (1990), Wendy Mitchinson’s The Nature of their Bodies: Women and their Doctors in Victorian Canada (1991), and Barbara Duden’s The Woman Beneath the Skin: A Doctor’s Patients in Eighteenth Century Germany (1991). Since that time there has been an outpouring of books on the body in various aspects but a lack of scholarship on the relational understandings of health, that is, how the “normative” state of health is deeply gendered.3 That “normative” state has become an idealized one that very few people can meet. The 1948 World Health Organization (W H O ) definition of the concept of health was “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”4 As Daniel Callaghan pointed out, through that definition human happiness became “one more medical problem, to be dealt with by ­scientific means.”5 It also led to “health as a condition of ideology as well as longevity” that masks inequalities and has the potential to individualize wider social problems.6 This critique has been developed further by Jonathan Metzl and Anna Kirkland in Against Health: How Health Became the New Morality.7 The way in which that idealized state works in popular culture is ­explored in Cheryl Krasnick Warsh’s recent collection Gender, Health, and Popular Culture: Historical Perspectives (2011), which covers a variety of topics on the transmission of health information and popular

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Introduction 5

representations of the body. Together, that collection and this one reflect the widening of understandings about the compass of health and interest in it. Many topics in both would not have been thought of as under the rubric of health history even a decade ago. While the Warsh collection focuses on the popular culture aspect of twinning gender and health, the focus of Bodily Subjects is less on popular culture and more on the way gender identity was reinforced over time by different meanings of health.8 To take but one example, in antebellum America, to be a man in working class communities was to be a manual worker and to be a worker required an able body. A man who chose not to work was, by definition, unhealthy. Good health was, therefore, synonymous with manhood. Celia Roberts has noted that “the history of biological bodies is ­important precisely because it shows … the lack of separation between scientific representations and the materiality of bodies.”9 Brigitte Fuchs’ examination of the gendering of bones in nineteenth-century central Europe indicates how representations of the body are social and ­cultural constructions resulting from scrutiny by “health” professionals. Similarly, Antje Kamp analyzes how a new medical specialty – that of andrology – arose to attend to the fertility of otherwise healthy men in post-war Germany. Bodies, then, were redefined through the work of medical specialists working with particular gendered frameworks. In their research, the international contributors to this volume have interrogated how embodied meanings of health changed over two centuries of Western culture embracing three continents. They have done so from a variety of historical perspectives, from the legal to the popular, using different methodologies, from close readings of medical texts to quantitative analysis of Poor Law records. Their histories are influenced by different theoretical concepts, from social control to cultural history’s attention to “the making of meaning,” that is, how women and men in the past, to use Mary Fissell’s words, “made sense of their lives, of the natural world, of social relations, of their bodies.”10 Our authors use a range of sources, including medical texts, found interviews, research reports, advertisements, men’s magazines, and the ephemera of health activists. The perspectives, methodologies, theoretical influences, and sources used are determined by the topics that the authors have inves­ tigated, all of which reflect the current expansiveness of the history of  health. Evident in the explorations around embodiment are the ways  that class and race often influence how health and illness are ­understood for women and men, and how dominant discourses and

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6  Bodily Subjects

subversive ones illuminate what is considered “natural” or “normal” in different times and places. Collectively, the chapters point to the ways that gender influences well-being and its perception, demonstrating the intersectionality that is evident when studying the history of gender and health. Bodily Subjects contributes to the history of medicine and health, as well as cultural, gender, and health studies. Gender has become a concept that is central to analysis in the humanities and social sciences. This one word serves to encapsulate a complex symbolic system through which the attributions “masculine” and “feminine” come to be embodied so that, “through social and cultural practice,” they have “become integral to customary ways of thinking, feeling and acting.”11 Complicated by class, ethnicity, religion, and age, gender is a lens through which those who look at the past seek to understand it. In the early years of gender studies, the goal was to eliminate the way in which the two-sexed model essentialized the body into two binary forms – men and women – by examining the meaning of masculinity and femininity and what being male or female signified.12 Wendy Mitchinson’s study of pharmaceutical advertisements for appetite suppressants, for example, finds that women were depicted as sedentary overeaters while men were depicted as active overeaters. These simple depictions worked within layers of cultural expectations of the appropriate roles of women and men in 1950s and 1960s Canada. Catherine Gidney’s study of students in Canada from 1900 to 1960 suggests how an emerging emphasis on “healthy” personal development held out seeds of new possible futures for women. The meanings of masculinity and femininity, therefore, are contingent and contested and influence understandings of health, a matter overlooked when the focus is on women’s health in isolation. The authors represented in this volume work within a relational understanding of gender in that ideas about normative behaviour for one sex have implications for ideas about normative behaviour for the other. While much of the scholarly work on the meaning of gender has been discursive in its approach, focusing on the way language makes meaning such as the nineteenth-century understanding of women as “the sex,” the corporeality and materiality of bodies cannot be dismissed.13 Both meanings, whether discursive or corporeal, strike at the heart of  the meaning of health.14 Gender can reflect how and why people became ill, why they were perceived to be ill, and how differently they were judged and judged themselves when they were. A I D S was first understood, as Natalie Gravelle analyzes, as a disease of homosexual

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Introduction 7

men, hence no thought was given to providing services for women. Women activists worked to shift this perspective so that women sufferers might receive treatment. By exploring gender and health as inextricably linked entities in the nineteenth and twentieth centuries, the essays in the collection add to our understanding of the systemic role gender played and continues to play.15 The World Health Organization has recognized the significance of gender and health in suggesting that gender norms and values “give rise to gender inequalities” that have an impact on “health status and access to health care.” It gives the example of a teenage boy dying in an accident because of peer pressure to take risks and the example of women, in some communities, who may not receive health care because they are unable to travel alone to clinics.16 Both are examples of how gender, health, and identity are enmeshed. History is replete with such examples of the way specific gender norms in time and place influence wellbeing, and this collection attempts to explore some of these. When heterosexuality is normative, for example, ideas about health serve as a form of “moralization” prescribing the boundaries of acceptable behaviour for the young, a topic explored in the chapter by Anika Stafford and Mona Gleason. The editors of the collection are mindful of how such history lives in the present and carries into the future. The historiography of health is rich and complex and in many r­ espects follows the changing nature of the discipline of history itself. The modern beginning of scholarship in medical history was in the study of medicine as a profession and the “great” men who practised it. Challenged by scholars such as Henry E. Sigerist, the history of medicine became more interpretive and contextualized. With the emergence of social and feminist history new queries about medicine, its power, and its influence came to the fore. That power and influence is still recognized by medical sociologists today. As Juanne Nancarrow Clarke argues, “The physician is not only a scientist but also a moral decision-maker. Medicine can legitimate the illness it diagnoses on the condition that the patient adopts the ‘sick role’ prescribed by the doctor. Medicine defines what is deviant from health and also how the patient is to react to that definition. Illness is legitimated deviance insofar as it has been identified by the physician and the appropriate steps are taken by the patient to get well.”17 Over time, the power of medicine resulted in what scholars, including historians, referred to as medicalization, the broadening of medicine’s gaze to incorporate a myriad of social problems in its purview. Historically

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8  Bodily Subjects

and culturally specific social issues such as sexual behaviour, discussed in the chapters by Thomas Wendelboe and by Anika Stafford and Mona Gleason, or even appearance, analyzed in the chapter by Tracy Penny Light, have come to be the subject of medical intervention. Recently there has been a backlash against the way social problems are continually incorporated into the medical domain and calls for medicine to return a more restricted emphasis on the care of the biological body.18 Medicalization as an interpretative tool denied the agency of individual women and men, who appeared powerless before their doctors. Social historians sought to reclaim the engagement of the individual by integrating the patient into studies of medicine.19 At first, the introduction of patients into the mix did not alter interpretations significantly away from ideas of social control and the political power perspective of  medicine and its practitioners. Eventually, however, historians saw patient “agency” as more significant in its variability and inventiveness. The resistance to medical practitioners of men, women, and children, ordinary and not so ordinary, at times reflects a strong sense of their own specific entitlement and the willingness of some to push against limitations not of their own making as well as against those that were. Integrating patient agency into the history of medicine eventually led to a shift in the understanding of the concept of power itself. Here was a governance that Lori Reed and Paula Saukko describe as both passive and active. Patients became recognized as both “objects of governance” and self-governing subjects. The practitioner / patient relationship became recognized as only one aspect of the multiple fluid and complex relationships that existed in health care and maintenance, some of which Reed and Saukko argue reflected a power “less hierarchical and more horizontal or network-like.”20 As Barbara Brookes’ study of the birth of disabled children in twentieth-century New Zealand suggests, parents worked hard through voluntary associations to create new opportunities for their children. Such voluntary associations, in a variety of realms, from cancer societies to psychiatric survivor groups, point to the importance of social networks outside of established health structures. A network-like understanding of health practices suggests the limitations of the early historiography – the context is far richer when one looks beyond a profession, a practitioner, and a patient and, until recently, a female patient more often than not. Expanding that perspective were those who went beyond the study of medicine and considered the significance of the “caring” professions. Nursing was the first to be studied, in part because of the feminist movement and its interest in the

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Introduction 9

antecedents to professional women. Following along were studies of dieticians, laboratory technicians, workers in asylums, and support ­ workers in hospitals and other state institutions. Such studies incorporated not only gender but also class and race through the nature of their topics and expanded the focus from medical to health care. The complications of understandings of health are evident in Meg Parson’s examination of an Aboriginal settlement run by the state of Queensland in Australia. For those in charge, hygiene took precedence over bodily health in an environment where cleanliness received more attention than nutrition. Understanding how the state of being “healthy” was understood in the past allows us to interrogate health practices, including those of public health, which too often had been overlooked, and ask questions about the vulnerability of bodies. Part of health’s richness as a subject for scholars is its ever-changing nature. Diseases seem to emerge and then disappear or at least become absorbed by another.21 Karl Figlio and Joan Jacobs Brumberg have written about chlorosis, which, in Brumberg’s words, “represented an entire conception of the female adolescent rather than simple anaemia.” It was prevalent in America from 1870 to 1920. Brumberg argues that while iron deficiency anemia “never disappeared, chlororis surely did precisely because the cultural and familial context that stimulated its construction changed dramatically.”22 Tracing the temporal and geographical specificity of ideas about health and disease helps lay bare the cultural context shaping those ideas. The chapters by Patricia Reeve and Marjorie Levine-Clark detail the way in which early in the nineteenth century the physical ability to work was bound with the notion of citizenship. Hygiene as an aspect of maintaining health is a theme overt in the work of Meg Parsons in the overseeing of Aboriginal health and lives in twentieth-century Australia. Thomas Wendelboe, however, describes how in mid-twentieth-century America using certain hygiene products had become a signifier of a masculine identity. Hygiene took on different meanings in these vastly different contexts. The meaning of health broadened in the twentieth century to include the psychological, as indicated in the chapters by Anika Stafford and Mona Gleason, Catherine Gidney, and Rebecca Godderis, and it eventually grew to incorporate the desire for and ability to have a different body through cosmetic surgery, as suggested by Tracy Penny Light. The authors in this collection identify the varying idealized images of health in the past and how they were used to counter groups deemed

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10  Bodily Subjects

the problematic “other” (the disabled, obese, poor, unattractive, infertile, homosexual, and non-white). In Western culture today almost anything can be sold under the rubric of health, from whole lifestyles to exercise equipment and vitamin supplements. There is an apparently insatiable appetite for products that promise to enhance well-being so that the quest for health goes far beyond the confines of the doctor’s office or that of other health professionals. The actors in the drama of health maintenance are many. In addressing health, the volume’s authors explore who gets to be the health “expert.” At times it is not doctors alone. What many of the authors in this volume reveal is the contested arena of expertise whether the challenge comes from other specialties within medicine, from families, from activists, from the corporate sector, or from the individual. According to Robert Crawford, “Since the 1950s, physicians and health educators, backed by a wealth of epidemiological knowledge, have made ‘lifestyle hazards’ or ‘at-risk behavior’ a matter of public awareness.”23 To be assessed as being at risk is to become an object of surveillance.24 The risks identified by epidemiological studies are focused on the population, not the individual. Nevertheless, risk has become of significant interest in historical research, and women and men have been shown to engage in different risk-taking behaviours with regard to smoking, drinking, and drug taking, for example. Rosemary Elliot has shown how men were the main subjects of study when the risks of smoking were identified and women were of peripheral interest. Men, therefore, were warned and took heed of the risks of smoking while women “emerged in the 1970s as the main growth area of the ­tobacco market.” Their invisibility in earlier studies made them subject to new and intensified campaigns by the tobacco companies, in effect heightening their risk of lung cancer.25 Health has become the dominant value in modern societies, a state that scholars refer to as “healthism.” As Robert Crawford puts it, “healthism is defined … as the preoccupation with personal health as a primary – often the primary – focus for the definition and achievement of well-being; a goal which is to be attained primarily through the modification of life styles, with or without therapeutic help … healthism treats individual behavior, attitudes and emotions as the relevant symptoms needing attention.”26 It is increasingly the individual’s responsibility to have and maintain the new view of health. The corollary, however, is blame if you fail.27 Rebecca Godderis’ chapter analyzing attention to postpartum depression in the 1980s suggests how individual women,

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Introduction 11

not their partners or the wider society, were held to account in the profamily agenda for their failings. Geographers remind us that “where people live significantly affects their health outcomes. This can include such dimensions as global differences in healthy life expectancy, comparisons of disease rates across regions of the world, reports of within country variations in health outcomes, and variations in life chances and health outcomes within specific localities.”28 The chapters in this collection reflect many of these geographical levels: a cultural, less national gaze at central Europe in the work of Brigitte Fuchs, the national specificity of post-war Germany by Antje Kampf, and the case study of English Poor Law in Stourbridge, England, by Marjorie Levine-Clark. A local study cannot help but be influenced by wider health trends and discourses but how the wider trends are applied can be locally specific. As Erika Dyke and Christopher Fletcher argue, “The qualities of place are woven into notions of health in ways that localize health, disease and medicine, while often simultaneously leaving intact powerful renderings of scientific knowledge that relies upon a more universal discourse.”29 Each chapter in this col­ lection is sensitive to the geographical place and time of the subject addressed. Bringing these widely different places (albeit in Western culture) and times together underlines the significant entwining of gender and health. Three unifying themes hold the essays in this collection together and each provides a focus for one of the sections: “Embodied Citizenship,” “Defining and Contesting Illness,” and “Authority and Ideals.” All of the chapters address gender and health and explore how the two intersect around the theme of normality: what is healthy (normal) and what is unhealthy (abnormal) and how these are visited on and experienced by the body. In addition to gender, race, class, and age become important factors of the body being discussed. The discursive aspects of gender and health inform many of the chapters, but all recognize that historical subjects had bodies that experienced weakness, strength, pain, and illness and that those experiences were shaped by society and culture. Out of the basic framework of gender and health has come the concept of embodiment, that is, how bodies are read for health and by whom. The chapters in “Embodied Citizenship” ask how people themselves conceived of their civic embodiment and how women and men differed in their relation to the polity. The chapters proffer answers through examining how bodily capacity (in the nineteenth-century northeastern United States and late nineteenth-century England), skin

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12  Bodily Subjects

colour (in Australia in the interwar period), and personality or psychological traits (in elite Canadian universities) enfranchised or disenfranchised women and men, limiting or expanding their entitlements and framing their role as citizens. The authors show that class position, race, and educational opportunities had an impact on notions of biological citizenship in which “different ideas about the biological responsibilities of the citizen are embodied in contemporary norms of health and practices of health education.”30 As the chapters reflect, gender was a determining factor in the way health was imagined. This section, then, highlights and brings together chapters that show the intertwined relationships between state, citizenship, and health for both men and women. “Embodied Citizenship” opens with two chapters that argue that, in nineteenth-century America and England, good health was the main currency of white working people, enabling them to labour and maintain independence. Patricia Reeve makes innovative use of railway company archives, legal records, and trade union publications to suggest how workers viewed civil corporeality. She examines the way in which white working men in the northeastern United States asserted manly self-rule, arguing for security of the person against the dangers of the workplace. Working women campaigned for the ten-hour day in order that they should not be in body – like slaves – at the caprices of employers. Both women and slaves were denied citizenship in the American Republic, but while white men equated health with independence, white women could be dependent and yet demonstrate civic duty as mothers and through their role in raising future citizens. In introducing an early debate that is ongoing – where does the responsibility for health lie – Reeve highlights the centrality of health as an identity and the fear that its loss entailed. Reeve notes how the only recourse to assistance for disabled workers lay through the indoor relief in the state’s poor law institutions. The English Poor Law and the gendered nature of welfare is the subject of Marjorie Levine-Clark’s chapter. Elaborating on Rose and Novas’ point that “specific biological presuppositions” have underlain claims to citizenship, Levine-Clark uses the applications for relief to the Stourbridge Poor Law Union in England’s West Midlands to examine the ways in which men’s citizenship relied on healthy bodies capable of work. Such was the close tie between being able-bodied and being a citizen that men in receipt of relief were not entitled to vote until 1918. Women, expected to be dependent on men, were deemed, by their very nature,

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Introduction 13

to be less able-bodied than men. For both, ill health provided “a respectable source of need” because assistance offered to restore the applicant back to their expected social roles in the realm of work for men and domesticity for women. Men’s health, Levine-Clark argues, was prioritized because men were imagined as working to support wives and children while women’s daily productive work remained unrecognized. Work also is at the heart of Meg Parson’s exploration of the construction of hygienic subjects in Queensland, Australia, where the indigenous Aboriginal people were required for labour but kept at a distance from white society. In this case race dictated the denial of citizenship: to be Aboriginal was to be without civil rights. Taking the example of the Cherbourg Aboriginal Settlement, Parsons examines how this large government-run reserve used ideas of health and hygiene to control the lives of its male and female inhabitants. Isolation and medical inspection of the Aboriginal people was deemed both a moral and a medical necessity to prevent miscegenation and to allay white fears about infection from the Aboriginal community. Aboriginal men were infantilized by their “protectors” while Aboriginal women were regarded as oversexed and uncontrolled. Parsons concludes that the emphasis on ­hygiene practices at Cherbourg overrode attention to health in that inhabitants might be judged clean (the appearance of health) but ­ ­suffered undernourishment. In contrast to the situations described in Reeve and Levine-Clark’s chapters, good health could not, for indigenous Australians, be a basis for independence, that is, citizenship, in the interwar years. Aboriginal people were cast as dependents of the state, even as that state required their labour and subjected them to medical surveillance, which operated differentially for women and men. That surveillance of Aboriginal reproductive and hygiene practices into the mid-twentieth century aimed to protect white society rather than to enhance the health of the Aboriginal community. Catherine Gidney examines a very different kind of citizenship at ­Canadian universities in the first half of the twentieth century. Universities saw their role as educating citizens, and good health was an essential part of that mission. Gidney delineates an early twentieth century focus on character that upheld individual self-sacrifice for the greater good, where womanhood required devotion to family and community and manhood entailed supporting others whether at the level of the family or the nation. By the mid-twentieth century, educators were emphasizing the importance of developing “sound citizens” through attention not just to bodily health but also to mental and emotional development

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14  Bodily Subjects

of the “total personality,” an expansion of what it meant to be a healthy individual. Gidney argues that this turn to individual self-realization held within it the seeds of potential change in reevaluating women’s citizenship. Women were empowered to imagine new futures where good health was no longer tied primarily to the domestic sphere. Health specialists at the universities in the post-war years increasingly focused on self-realization, a shift that had particular implications for women. Such an expansion of understandings of health beyond the able body to the psychological underpinned the 1948 World Health Organization definition of health as a state of “complete physical, mental and social well-being.” “Defining and Contesting Illness” is the second theme and section of the volume, where the authors interrogate the gendered meaning of particular conditions: osteomalacia, infertility, infant disability, and A I D S . In doing so they introduce the interaction between medical expertise and the recipients of medical care. The first two chapters examine definitions of debility and reveal that medical authority was not always of one mind as practitioners and researchers contested definitions, diagnosis, and treatment. The next two chapters in this section use the notion of medical authority to define disease and examine how an internal medical debate about disease became a public debate as lay people took it upon themselves to contest definitions of disability and disease that limited the potential for assistance to those in need. These four studies, then, throw into relief the way in which illness is read through gender: bones as being sexed; infertility in men; familial “health” with gendered responsibilities; and A I D s as a gay plague, a definition women had to contest. All demonstrate interactions between sufferers and “experts” and the way in which definitions of health emerge in various contexts. Brigitte Fuchs explores the way in which Central European medical texts in German from the last third of the nineteenth century were ­imbued with gendered understandings of bones. Early explanations for osteomalacia, an “abnormal flexibility” and softening of the pelvic bones, focused on women’s reproductive organs. Removal of “hyperactive ovaries” through oophorectomy was offered as a solution, increasing the prestige of gynecologists, until critiques of the operative procedure came to the fore in the 1890s. A new solution, which ­involved treating patients with hormonal matter from animal ovaries, reveals the way male experts made women the testing ground for their theories of  disease causation. Medical specialists were keen to try untested

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Introduction 15

therapies on their women patients, and mortality rates were high. Understandings of osteomalacia pivoted around conceptions of women’s reproductive capacity and how it might cause self-destruction. Male reproductive capacity is at the centre of Antje Kampf’s study of male bodies in post-war Germany. Kampf aims to shift the spotlight from the female to the male reproductive body and, in doing so, she explores the rise of andrology as a specialty out of what was a competitive environment of medical disciplines, including gynecology, dermatology, sexology, and physiology. Unlike earlier histories of gender and health where the male body has been regarded as the norm and the ­female body as problematic, Kampf problematizes the male body and explores how ideas about “manly dignity” complicated approaches to understanding male infertility. Infertility in men had long remained in the shadows because of the centrality of potency to the very definition of masculinity.31 Men’s reproductive role was of importance to the nation with regard to questions of paternity and population politics. But the story of failing male bodies remained backstage, central only in the discussion of those specialists who made of the male body a new project to be medically dissected. The final two chapters in this section relate to contesting disability and illness and their gendered meanings. Barbara Brookes’ chapter ­explores the implications of the birth of a developmentally impaired infant for families in New Zealand in the mid-twentieth century. Such an event was thought to undermine the health of the family as a whole by upsetting future expectations. Unlike the usual assumption of motherly devotion, mothers of mentally impaired children were frequently exhorted to part with their infant and place the child in institutional care, a pathway fathers were often keen to follow. In the mid-twentieth century, parents were complicit with the medicalization of disability, seeking help from the medical profession to understand the prognosis for their children. Yet parents also contested, in various ways, medical and social definitions of “normal,” seeking to have access to education, for example, for their children. Through their activism they provided a public narrative about disability that had the potential both to assist individual parents, but mothers in particular, and to bring about wider social change. Focusing on Canada, and Ontario in particular, Natalie Gravelle examines the way in which H I V /A I D S was initially cast as a male disease and traces the blindness to gender among many researchers and practitioners and the state. The fact that women also contracted the disease

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16  Bodily Subjects

was obscured and, therefore, they were left out of prevention campaigns. Gravelle illustrates how women activists, through groups such as A I D S A C T I O N N O W and Voices of Positive Women, contested the representation of H I V /A I D S as a solely male disease and brought about change. Women activists produced flyers, pamphlets, and articles to highlight the fact that women could get H I V /A I D S and encourage women to get tested. Workshops and demonstrations, including a “diein” on World A I D S day in 1990, helped draw attention to the fact that women with A I D S died more quickly than men with A I D S and highlighted the need for more research on women sufferers. Such research indicated that women had distinct clinical experiences and confirmed the view of activists that the needs of women living with H I V /A I D S were not the same as those of men. Gravelle reveals the gendered politics of the A I D S epidemic and the importance of grassroots activism to create change. The third theme, “Authority and Ideals,” addresses the ways in which health, identity, and morality are closely linked in Western society and how they infuse popular culture. Each chapter looks beyond medical definitions to the way the wider culture structures health through norms. Casting certain lifestyles and behaviours as healthy served to make others appear pathological. Any “ideal of health” holds within it a critique of other ways of being and thus health becomes part of the disciplinary regime analyzed by Michel Foucault.32 Health acts as a “language of betterment” and a “consumerist rhetoric” that “explicitly justifies particularly corporeal types and practices, while implicitly suggesting that those who do not play along suffer from ill health.”33 This rhetoric has been present in different times and places to address cultural anxieties and interests in what is healthy and normal. Our authors question authority and ideals that inform definitions of health in probing normative ideas of sexuality, appearance, and motherhood. Anika Stafford and Mona Gleason use the example of social work outreach in Alexandra Neighbourhood House in Vancouver to explore the way in which heterosexuality was regarded as normative and, consequently, the ways that social workers understood normal childhood ­sexuality. Here we see how social workers captured and employed current ideas about normal development. In 1950s suburban Canada, the definition of health extended beyond the physical to the psychological, and of particular concern was the psychological health of children. Adolescents and younger children were expected to develop an “ideal” heteronormative sexual orientation, and patterns of behaviour that

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Introduction 17

suggested otherwise were stigmatized and made pathological through the authority of social workers. Health, then, became a marker of exclusion for those who resisted heterosexuality. Ironically, in fighting what appeared to be resistance to heterosexuality, social workers signified a fear of its fragility. The close tie between health and heterosexuality and the view of homosexuality as pathology is at the heart of Thomas Wendelboe’s chapter on health and hygiene advertisements in Playboy and Esquire magazines in Cold War America. In this chapter, Wendelboe suggests that reading popular culture can give us new insights into the construction of gender and health. Advertisements in the magazines used the language of health and hetero- and hyper-male sexuality to encourage consumption of hygiene and toiletry products. Linking products to success at sport was a key part of a marketing strategy that used health to reinforce male heterosexuality and convey a particular ideal of health to sell goods. The rubric of health became a powerful marketing tool in the American post-war era, playing on fears that poor hygiene would lead to personal social failure. In the advertisements the banal became dominant. Wendelboe concentrates on the depictions of the male body that aspired to an ideal of strength, cleanliness, and good grooming for men that implied heterosexual “success” thus essentializing normative masculinity to sexual performance. Wendy Mitchinson is also concerned with advertisements and ideal bodies, but within the realm of medicine. Her chapter explores the way in which pharmaceutical companies aimed to educate doctors about methods of treating obesity, a condition that became of significant concern in post-war Canada. To sell products, the companies built on the idea that the slender body was a healthy body. In doing so they appealed to popular cultural conceptions of the roles of men and women and their different relationship to food. Businessmen might inadvertently overeat during their busy business days, while emotionally needy and frustrated women ate to while away their empty lives at home. Depictions of “ideal” women were also used in the advertisements to lure the doctors, most of whom were male at the time, to look more closely at the information conveyed. Through these visual and textual sources, Mitchinson suggests, we can see how the pharmaceutical companies entered into a compact with the medical profession, suggesting remedies for obesity that worked within wider cultural understandings of gender. No drug regime, however, could create the “perfect” mother, an ideal that invokes a cacophony of voices, voices that became particularly

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18  Bodily Subjects

strident in the neo-liberal regime of 1980s America. An outpouring of medical literature on postpartum depression located the problem within the individual rather than exploring the social, political, and economic context in which mothering takes place. Ideals of motherhood are at issue in Rebecca Godderis’ examination of the sharp rise of interest in postpartum depression in the United States in the 1980s. She traces how the wider sociopolitical context influenced the formulation of research and treatment for depression after birth, which earlier had received little attention, highlighting how place and time matter. In particular, Godderis suggests that the 1980s right-wing pro-family agenda fostered psychiatric interest in postpartum depression and, by locating the problem in individual psychology, took the focus off wider gender issues. In this example of healthism, only the individual, not their ­cultural context, is found to be at fault. Women’s biological citizenship was once again recast to emphasize their role as wives and mothers. Postpartum depression presented an “extreme contradiction” in the face of normative gender roles as the women who suffered from this illness did so “because of motherhood.” The close entwining of health and normality working to exclude difference comes to the fore in Tracy Penny Light’s discussion of cosmetic surgery in twentieth-century Canada. Penny Light raises important questions about the role of medicine in constructing normality. She teases out the complex role of the physical and psychological in cosmetic surgery where a person’s experience of enhanced health might be reliant on a certain bodily aesthetic, and perhaps more so for women as the demand for breast augmentation suggests. Surgery might then be seen to be moving from the repair of defects in the “unhealthy” to an enhancement of already “healthy” bodies. Gender identity disorder, first listed in the Diagnostic and Statistical Manual of Mental Disorders (D S M -III) in 1980 may itself call for surgical therapy. Unlike the advocates of disability studies who critique the wider society for its inability to accept bodily difference, the advocates of therapeutic surgery seek individualized medical solutions to perceived problems of discrimination. The chapters in Bodily Subjects suggest the manner in which health is a mobile and gendered subject. Mapping the way it has been understood historically alerts us to how it resists any kind of fixity and, indeed its continual expansion in the twenty-first century. The historical studies presented here – of the embodiment of citizenship, of definitions of ­illness and their contestation, and of authority and ideals – add to current debates about the way health has become the new morality, and a

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Introduction 19

morality that acts differentially according to gender. Judgments made on women (she’s overweight) and men (he doesn’t get enough exercise) in the name of health rely on the assumptions that masculinity and femininity are transparent categories. They also rely on the assumption that health is a universal good.34 Critical studies about the culturally embedded nature of what, at first glance, may seem to be scientifically objective readings of health can enhance the prospects of confining health to but one of the many conditions that determine the life prospects of individuals.

NOTES   1  Saltonstall, “Healthy Bodies, Social Bodies,” 12.  2 Foucault, The History of Sexuality, 92–6.   3  Sargent and Brettell’s Gender and Health: An International Perspective is an ­important contribution primarily from an anthropological perspective. Eisler and Hersen’s Handbook of Gender, Culture and Health is a collection of contemporary studies addressing gender and health. Studies that take the body as a focus include Giblett, The Body of Nature and Culture; Terry and Urla (eds.), Deviant Bodies; Berdayes, Esposito, and Murphy, The Body in Human Inquiry; Casper and Currah, Corpus: An Interdisciplinary Reader on Bodies and Knowledge.   4  Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June 1946, signed on 22 July 1946 by the representatives of 61 states (Official Records of the World Health Organization, no. 2, 100) and entered into force on 7 April 1948; Metzl and Kirkland, Against Health, 7.   5  Quoted in Crawford, “Healthism and the Medicalization of Everyday Life,” 381.   6  Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June 1946; signed on 22 July 1946 by the representatives of 61 states (Official Records of the World Health Organization, no. 2, 100) and entered into force on 7 April 1948; Metzl and Kirkland, Against Health, 7.   7  Metzl and Kirkland, Against Health.   8  For sociological inquiries into health and identity see Kelleher and Leavey, Identity and Health.   9  Roberts, “A Matter of Embodied Fact,” 21. 10  Fissell, “Making Meaning from the Margins,” 365. 11  Jordanova, “Gender and the Historiography of Science,” 476.

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20  Bodily Subjects

12  For work that has explored historical understandings of the sexed body, see, for instance, Laqueur, Making Sex; Fausto-Sterling, Sexing the Body; Butler, Gender Trouble; Foucault, The History of Sexuality. 13  Braun, “Accounting for the Contribution of Vitamin B to Canada’s W W I I Effort,” 518. Braun uses the work of Colebrook, “Questioning Represen­ tation,” and William Paulson, “For a Cosmopolitical Philology: Lessons from Science Studies,” for this point. 14  There has been much work on the ways gender and health are understood. 15  We build on the important work on gender and health by scholars before us. For instance, see Lorber, Gender and the Social Construction of Illness; Mitchinson, The Nature of Their Bodies; Reed and Saukko, Governing the Female Body; Fausto-Sterling, Myths of Gender; Jordanova, Sexual Visions; Keller, Reflections on Gender and Science; Gough and Robertson (eds.), Men, Masculinities and Health. 16  World Health Organization, “Gender, Women and Health,” http://www. who.int/gender/genderandhealth/en/index.html 17 Clarke, Health, Illness, and Medicine in Canada, 237. 18  For a critique of this backlash through the work of Le Fanu, The Rise and Fall of Modern Medicine, and Fitzpatrick, The Tyranny of Health, see Gard, The End of the Obesity Epidemic, 160–2. 19  For instance, see Hunter, Doctor’s Stories; Mitchinson, Giving Birth in Canada; Shorter, Bedside Manners. 20  For insights into governance see Reed and Saukko, Governing the Female Body, 2–3. 21  Tone and Siegel Watkins, Medicating Modern America, 6. 22  Brumberg, “Chlorotic Girls,” 194; Figlio, “Chlorosis and Chronic Disease in Nineteenth Century Britain.” 23  Crawford, “Risk Ritual and the Management of Control and Anxiety in Medical Culture,” 508–9. 24  Ibid., 514–15. 25 Elliot, Women and Smoking Since 1890, 130. See also Cook, Sex, Lies and Cigarettes, and Rudy, The Freedom to Smoke. 26  Crawford, “Healthism and the Medicalization of Everyday Life,” 368. 27  Ibid., 378. 28  Tunstall, Shaw, and Dorling, “Places and Health,” 6–10. doi:10.1136/ jech.58,1.6. See also Dyck and Fletcher, eds., Locating Health: Historical and Anthropological Investigations of Health and Place, 3–4, and “Introduction.” 29  Dyck and Fletcher, Locating Health, 3. 30  Metzl and Kirkland, Against Health, 7.

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Introduction 21

31  For a history of potency and masculinity see McLaren, Impotence: A Cultural History. 32  Snyder and Mitchell, “Afterword – Regulated Bodies: Disability Studies and the Controlling Professions,” 117. 33  Metzl and Kirkland, Against Health, 4, 6, 3. 34  Ibid., 2.

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Section One

Embodied Citizenship

This section addresses the way governments in diverse settings rely on particular and historically specific conceptions of the body. The rights and duties of citizenship in the countries considered here were first granted to men. A study of working men in the northeastern United States in the early to mid-nineteenth century demonstrates how they claimed to exert “manly self-rule” through the body. Good health – represented by an able body – allowed them to exercise independence in pursuit of employment and thus gave them the ability to support their dependents. Those dependents, women and children, were denied citizenship in the American Republic, but women’s civic duty lay in their role as mothers, raising future citizens. Women’s role as dependents was also central to the family economy in England in the late nineteenth and early twentieth centuries. Women pregnant outside of marriage, or widowed with no male support, were more likely than married women to seek relief from welfare authorities. An analysis of a large data set of applications for relief from the Stourbridge Poor Law Union demonstrates the close connection between self-government of the individual man and his participation in the body politic. Men in receipt of relief lost their right to vote and hence their political citizenship. Biological assumptions about the different bodily capacities of women and men, in effect, shaped the individual’s access to welfare. In an analysis of an Aboriginal Australian settlement in Queensland, Australia, the state’s close investment in a clean and compliant labour force, kept at a distance from white settlement, is revealed. This study shows how hygiene, as a concept, was closely linked to ideas of a duty to labour. But Aboriginal people were denied civic capacity and were instead trained with the aim of making them a docile labour force. Their

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24  Embodied Citizenship

very embodiment marked them as subject peoples. A very different type of training evolved for twentieth-century Canadian university ­students when colleges put more emphasis on health. A study of tertiary educational institutions analyzes the gendered imagining of the ­citizen. The expectation that young men’s duty as citizens compelled them to put their bodies on the line in wartime was not applied to women because of women’s reproductive role. New psychological ­theories after the Second World War emphasized the realization of the self as part of a healthy life and, in doing so, opened up the possibility that women’s contribution to the body politic might reach beyond family life. The author argues that an emphasis on self-determination made it possible for women to debate the terms on which gendered expectations limited their citizenship. These four studies, then, suggest how the rights and duties of citizens rely on concepts of health that are deeply gendered and raced. To be a healthy man was to labour for one’s family in both early nineteenthcentury America and late nineteenth-century England and labour was an expected part of citizenship. In stark contrast, the labour of Australian Aboriginal people, which was important in the success of the Queensland state, made them into objects of state surveillance and control rather than citizens. Humiliating gendered regimes in the name of hygiene stood as a substitute for any real attention to bodily health. Surveillance over the bodies of white middle class students at Canadian universities became more pronounced in the twentieth century as health services expanded. Health conceived of as psychological self-fulfillment paved the way for new forms of gendered citizenship.

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1 The “Bone and Sinew of the Nation”: Antebellum Workingmen on Health and Sovereignty P at r i c i a A . R e e v e

Thirty-five years after American revolutionaries had risked all for freedom, white workingmen in the northeastern United States invoked that struggle to challenge the effects of industrialization on their health and independence. From the 1830s to the Civil War in the 1860s, male wage earners asserted their right to liberty and security of person in response to the increasing perils of their employment. As production intensified and employers neglected to mitigate the hazards of industrial work­ places, occupational injuries and fatalities occurred with growing frequency. Labourers imputed their endangerment to their employers’ reckless pursuit of profit and unbounded authority over employees. As workers perceived it, the circumstances in which they laboured undermined their health and in turn jeopardized their social and civic status. Workingmen took as given that free will was exerted through (and over) the body, a venerable idea in a republic that contrasted manly self-rule with the presumed social and legal disabilities of women and slaves, including denial of their self-ownership. It followed that disabling assaults on male workers’ bodies in the workplace undermined their independence. Conversely, unfettered enjoyment of the right of person secured one’s capacity for self-determination by preserving the body, carrier of the will. Reasoning thus, male labourers conceived the requirements of antebellum citizenship – manliness, healthfulness, and bodily agency – as interdependent and vested solely in white men. Put differently, workingmen had posited the terms of corporeal citizenship, which derived

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26  Embodied Citizenship

from their gendered and racialized readings of human capacity.1 Though Massachusetts had enfranchised labouring men in 1821 (with limitations),2 workingmen’s imperilment in the workplace compelled them to define citizenship as both a legal and embodied identity. Consequently, they distinguished normalcy – manly possession and control of a “whole and healthy” body – from abnormalcy – a state of dependency arising from an impaired, unwholesome, and defenceless body.3 Moreover, labouring men (like Americans generally) believed that adherence to the requirements of hygienic living was a marker of individual respectability and fitness for citizenship. Yet workingmen found it increasingly difficult to act on antebellum precepts of health in the industrial workplace. Consequently, wage earners concluded that their standing as freeborn men was tenuous so long as occupational casualties were deemed accidents rather than the fruit of employer avarice.4

Labouring Bodies in the Historical Record Workingmen’s commentary underscores the centrality of their health and bodies to the history of proletarianization, yet US historians have not interrogated this idea until recently. Thus occupational casualties figure in historiography as naturalized by-products of industrial capitalism and as catalysts for workers’ mobilization, pluralistic policy-making, and the growth of the federal welfare state.5 The significance of these accounts aside, workers’ bodies remain absent from but implicated in the literature. Needed is an analytical framework that problematizes workingmen’s corporeality and so reveals what “might otherwise remain imperceptible” in the history of occupational casualties.6 For example, concepts of manhood and citizenship have imprinted labouring bodies and as a result they have been varyingly susceptible to workplace injuries.7 Workers’ bodies have also been “signifiers … of moral and hygienic visions and dangers.”8 In 1846, the physician John O. Green implied this while vouching for the superior health and character of Massachusetts mill workers relative to English operatives. “In all their hygienic [and moral] aspects,” he expounded, “there could hardly be more striking contrast.” This was welcome news in an era when the factory system was a bellwether for American civic virtue.9 Working bodies have also figured in the terms of the labour contract, for wage earners contract out their bodies when selling their productive powers. To quote Carole Pateman, the worker “cannot be separated from his capacities, he sells command

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Antebellum Workingmen on Health and Sovereignty   27

over the use of his body and himself.” Inattention to this has obscured employers’ control of labouring bodies, which were and are in turn the material basis for exertion of managerial authority.10 Furthermore, wageearning bodies have been sites of contestation and “intervention … ‘on which laws, morality, values, [and] power are inscribed.’”11 This is evidenced by policy debates over the origins and abatement of industrial accidents. At stake was the right to determine the instrumentality of the wage earner, to allocate the risks of production, and to define acceptable risk levels on the shop floor. These negotiations have conditioned workingmen’s abilities to safeguard their health and person, to provide for themselves and their dependents, and to lay claim to the rights and prerogatives of masculine sovereignty. These ideas inform this chapter’s analysis of assaults on antebellum workers’ bodies in the industrializing workplace. The unprecedented frequency and deadliness of industrial casualties were consequential exigencies for workingmen and their dependents. Thus, occupational accidents gave rise to explanations of the circumstances that promoted “bodily suffering.”12 The resulting narratives – by male labourers, their employers, and lawmakers – were steeped variously in antebellum medical wisdom, the ethos of the marketplace, and scripture. These countervailing discourses explored the meaning and alienability of health; the primacy of religious, medical, and market-based valuations of the body; and the importance for personhood of health status, personal physical autonomy, and the liberty of bodily defence. Close reading of diverse sources animates the argument that follows. These include medical treatises, business records, state appellate decisions, trade union publications, and workingmen’s legal testimony. The interplay of ideas advanced in these texts had two profound effects. First, it shaped “the terms in which” workingmen explained their endangerment at work and its effects on their person and status. Second, it established the imaginative possibilities and limits of workers’ ideas about civil corporeality.13 The explanatory power of these ideas would determine whether Americans viewed workingmen as the masters or subjects of their bodies.

North America’s First Proletarians Workingmen in the Commonwealth of Massachusetts were among the first Americans to interpret the risks of industrialization as an infringement of the right to bodily integrity and autonomy, the birthright of

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sovereign men. Their residency in the nation’s leading manufacturing state explains this fact. As it happened, labourers’ critiques of indus­ trialism arose alongside American elites’ celebration of the salubri­ ousness of the nation’s manufactories as compared with conditions in English enterprises.14 New markets for finished goods had ignited business incorporation in Massachusetts (also known as the Bay State), including textile mills and railways.15 Manufacturing output burgeoned as entrepreneurs adapted new technologies to production and integrated the manufacture and distribution of goods into large-scale enterprises. Employers in other sectors, such as construction and shoe manufacturing, increased productivity not through mechanization but by subdividing and deskilling handwork, a process termed metropolitan industrialization.16 Soon Massachusetts was “the most thoroughly industrialized portion of the globe outside Great Britain.”17 Imperilled Bay State wage earners advanced their claims in suits for damages over injuries and in mobilizations for a shorter workday. Gilham Barnes and Nicholas Farwell filed precedent-setting suits for damages against their employer, the Boston & Worcester Railroad, in 1837 and 1839, respectively. (Personal injury suits were quite rare before this time.)18 Barnes had worked as a contract employee for the corporation from March 1835 to June 1837 and was responsible for “tarring and gravelling bridges, all the way from Boston to Worcester,” Massachusetts. Farwell had been an engineer on the line from 1835 to 1837.19 During its deliberations the court did not distinguish the railway’s duties to its contract employee and in-house engineer. The plaintiffs claimed that the railway was liable for its servants’ occupational injuries, including those caused by negligent co-servants (called fellow servants), as was the case with Farwell.20 Whereas court-appointed referees settled Barnes’ case, Farwell’s claims received full judicial review. In 1842, the state’s highest court decided in favour of the railway in Farwell v. Boston & Worcester Railroad, an opinion that established employers’ non-liability at law. The ruling would not be wholly overturned until 1911, when Massachusetts enacted a system of workmen’s compensation.21 Even as Barnes and Farwell sought legal redress, proletarianized artisans pressed employers and legislators for maximum hours legislation. Organized handworkers decried their “excessive toil” – a consequence of working 12- to 14-hour days at accelerated labours – and declared themselves the “undaunted enemies of … mental, moral and physical degradation.” Before long, operatives in the textile centre of

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Lowell, Massachusetts, also had demanded (what they called) the tenhour day. Through the 1840s, hundreds and then thousands of mill workers, most of them women, petitioned lawmakers to enact shorter hours, reminding them that “toiling Maiden[s]” endured conditions worse than those of the “Russian serf.”22 Though the demands of labouring women are incidental to this analysis, juxtaposing their critiques of industrialism with those by workingmen reveals the gendered anxieties that animated the latter’s arguments. Whereas female workers claimed that their unwholesome occupations corrupted womanly hygiene and virtue, male labourers argued that industrial hazards threatened to disable them both literally and figuratively. At stake for workingmen was their capacity for self-rule. Ultimately, both men and women saw good health as an underpinning of individual identity and respectability; hence, they feared being unsexed and debased by their labours.

Antebellum Readings of Health Antebellum workingmen advanced their interpretations of health alongside other potent and divergent readings of wellness and its requirements. For example, medical authorities and clergy characterized health as sacrosanct, and as attainable so long as individuals obeyed the “laws of health,” including avoiding “intemperate and sensual excesses.”23 The idea that individual health and conduct were conjoined was well established, but after 1830 it enjoyed resurgence among Americans made anxious by urbanization, industrialization, and the expansion of a wage-based economy. As Martha H. Verbrugge has argued, the “rules of health were … guideposts toward security and virtue in an era of uncertainty.”24 The result was the crystallization of hygienic citizenship, a limited (and limiting) ideology that ascribed well-being to assiduous personal health maintenance and illness to willful self-neglect. Health status was, then, a product of individual choice and character. Related to this, medical authorities avowed that the mind and body functioned or failed in tandem. It followed that mental disequilibrium caused by dissoluteness resulted in ill health.25 Exponents of these ideas included self-named physiologists who extolled the benefits of good nutrition, exercise, and the like. In this context, individuals who violated the laws of health risked “becoming near pariahs.”26 Antebellum Boston and New York pulsed with these ideas, as Verbrugge has argued.27

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In contrast, the ethos of the marketplace sustained employers’ commodification of employees’ health and bodies. Embodied labour power, once a personal estate of incalculable value, could now be distinguished from the worker’s person and valued according to supply and demand. According to the terms of the employment contract, workingmen ceded control over their bodies to employers and became their instruments. As such, male labourers had little or no power to safeguard their person. Indeed, the figurative splitting of workers’ mental and physical capacities delimited their autonomy, for workingmen could not exert their will without authority over their bodies. By any measure, the commodification of working bodies had abrogated the laws of hygiene and the terms of corporeal citizenship. Subsequently, nineteenth-century workingmen would confront formidable barriers to self-care and self-rule.28 Humanitarianism – a markedly different ideology – inspired Americans to question their assumptions about pain, infirmity, and relational violence. Humanitarianism blossomed in the late eighteenth-century Anglo-American world and flowered in the United States after 1800.29 Nurturing it were the Second Great Awakening (a series of evangelical revivals that swept the nation from the 1790s to the 1830s), abolitionism, and the increasing popularity of sentimental literature. Elizabeth B. Clark has argued that evangelicalism increased American regard for compassion, which in turn engendered emotion-laden framings of social issues. These developments fostered audience receptivity to abolitionist writings that excoriated slavery and the violence it visited on slave bodies and minds. Likewise, sentimental fiction encouraged its readers to empathize “across barriers of status and race.” Clark concludes that the convergence of these benevolent tendencies engendered new ­“arguments for a ‘right’ to bodily integrity.”30 Though contradictory, these discourses were alike insofar as they attributed one’s circumstances and relations to individual choice. The era’s valorization of free will – an artefact of republican principles of government, evangelicalism, and the emergent free market theory – obscured structural limitations on individual agency.31 These included the social stratification of white men and long-standing inequalities in gender and race relations. Industrialization exacerbated these inequities even as the gospel of self-reliance masked them.32 Likewise, the veiling of these injustices – and attendant health disparities – militated against their amelioration through social negotiation and state action. Generally, the accent on individual responsibility was both “health denying”33 and an illiberal accounting of the preconditions to masculine

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autonomy. Nevertheless, workers mounted stiff challenges to the ­cultural fiction that freeborn men were equally unencumbered and, therefore, similarly capable of preserving body and self. Workingmen made their case even as medical authorities and industrialists framed and reframed the meaning and legitimate uses of the body.

T h e L aw s o f H e a l t h a n d B o d i e s a t L aw Unlike other physicians of his day, Benjamin W. McCready recognized that industrial workers were endangered by their occupations. In 1837, the New York native published the nation’s first treatise on the health effects of diverse trades and professions.34 McCready began by tallying the prerequisites to good health, including nutritious food, exercise, and “employment of the intellect.” He hastened to add that labourers faced many barriers to healthful living. On the basis of his interviews and correspondence with workingmen, McCready concluded that US workers were “confined to an impure atmosphere; many labour longer and harder than is consistent with … perfect health … [and] are subjected to the deleterious influence of dust.”35 McCready’s analysis combined the precepts of physiology, empirical methodology, and unprecedented insight into the subjugation of workers. McCready was distressed by wage earners’ ignorance of the “laws and functions of the … body,” but he insisted that the “unhealthy appearance of our population” was attributable to other causes. These included low wages, malnutrition, and unsanitary working conditions. Each was the result of the nation’s “unexampled” development, or so McCready reckoned.36 The doctor concluded by posing a question for his readers, namely, “Can we expect men who live thus to be sober and orderly, or women to be cleanly and domestic?” His query invoked ­established markers of male and female respectability and illuminated the differing costs of ill health for men and women. McCready’s question also underscored the disjuncture between workingmen’s degradation in the workplace and the conceit that sovereign men controlled their person.37 Yet, McCready did not critique the modes and relations of production that engendered ill health among workers; instead he admonished employers to safeguard workers “who are their instruments” and “under their control.”38 With this statement McCready ­tacitly ­likened wage earners to machines (his concern for their intellectual development notwithstanding) and conceded the legitimacy of employers’ authority over their employees. Left unanswered was the

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question of how workers would secure health within the confines of the employment relation. Still, McCready was remarkable for having understood that workers were encumbered in their quest for health. His challenge to the ideals of hygienic citizenship would not find a receptive audience among ­medical professionals until the germ theory was “developed, proved, and popularized in Europe and North America between about 1850 and 1920.”39 Only physician Josiah Curtis came close to seconding McCready’s argument. In 1849, Curtis published his study of the health effects of Bay State factories. Unlike McCready, Curtis excused employers’ failure to incorporate “hygienic and sanitary measures” in the workplace. As he saw it, it was “glory enough” to build cities; he did not expect entrepreneurs to “comprehend … the mysteries of typhus … or contagion, and the relation of these to ventilation, sewage, and water supply.” Like McCready, however, Curtis urged medical men to “guard the rights of generations yet unborn” by educating industrialists about the costs of “hygienic neglect.”40 That McCready was swimming against the tide is evidenced by the acclaim that greeted a treatise by the eminent physician and physiologist Elisha Bartlett. Whereas McCready asserted that unhygienic living and working conditions engendered illness, Bartlett ascribed ill health to self-indulgence and imprudence. In 1838, Bartlett wrote that human beings were obliged to foster “those conditions upon which bodily health depend[ed].” Success in promoting these circumstances would enable men and women to secure the body’s “fullest development, its fullest perfection,” thereby allowing them to achieve the “noble [and differing] ends” for which their bodies were created by God.41 Bartlett advanced these ideas while serving as mayor of Lowell. During his term, Lowell’s textile operatives turned out to protest wage cuts that threatened their household economies, the determinant of family nutrition and housing, expenditures on health care, and self-rule.42 In 1849, the pioneering statistician and physician Lemuel Shattuck upheld and extended Bartlett’s assertion that wellness was within personal control. Though a committed empiricist, Shattuck was also a physiologist who idealized health as “a possession capable of … growth or decay.” As he saw it, health “and even death itself, are, in some measure, within the control of man” because God had “framed” the “laws of nature, [which are] applicable to the life and health of man.” The good doctor predicted that if men understood and complied with these laws, they would guarantee themselves a “ripe old age.”43 Thus

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he intimated that free men faced but two barriers to health: ignorance and negligence. Shattuck also theorized that successive individual acts of immoderation jeopardized public health; hence, he charged the Commonwealth with stewarding the well-being of the citizenry. While serving as state senator, Shattuck persuaded fellow lawmakers to mandate the registration of vital statistics. The result was the nation’s first social investigation into individual health status, which produced the path-breaking “Report … to Consider the Expediency of Modifying the Laws Relating to the Registration of Births, Marriages, and Deaths” (1849).44 Shattuck’s interpretation of the data upheld conventional wisdom that illness derived from individual injudiciousness rather than systemic factors such as poverty. Among other things, he attributed the prevalence of disease in working-class enclaves to ignorance and immoderation. It followed that denizens of these neighbourhoods had failed to uphold the requirements of wellness. Thus persuaded, Shattuck held the state liable for investigating and eradicating behaviours that threatened the body politic. Wage earners who were no closer to preserving their health were now susceptible to government policing of hygienic citizenship. Conversely, Shattuck’s mobilization of the state suggested that workers might harness its powers for their own ends. By insisting that individual choices dictated health, Shattuck and likeminded physicians underscored the challenges and rewards of health maintenance in antebellum America. The populace had a tenuous grasp on wellness owing to the prevalence of disease, the dangers of childbirth, and the primitive state of medical therapeutics.45 Nonetheless, health was valuable cultural capital in a republic where slaves provided a negative reference point for wellness. Squandering this capital was tantamount to (and no more countenanced than) forfeiting independence or respectability.46 Antebellum healers well knew the difficulties of individual health maintenance, yet most did not adopt systemic approaches to preventive medicine except in cases of epidemic. It is unsurprising, then, that physicians were deaf to McCready’s argument concerning the social and environmental determinants of health. Medical authorities had severed the links between individual choice and circumstance, as would other commentators of the day.47 One year before the United States engaged in fratricidal conflict, the influential educator Catharine Beecher asserted that illness originated in “a want of knowledge” about the “body and … health; and … a want of thought and conscience on the subject.”48

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It followed that infirmity marked one as medically illiterate, neglectful of one’s person, or both. Neither circumstance aided masculine self-reliance. While the antebellum medical gospel had its challengers, none was more powerful than the principle that embodied labour was a commodity. In 1842, the Massachusetts Supreme Judicial Court codified this idea in Farwell v. Boston & Worcester Railroad. The question before the court was whether the railway was liable to pay damages to engineer Nicholas Farwell, who was disabled during a collision caused by a negligent fellow employee. Writing for a unanimous court, Chief Justice Lemuel Shaw ruled that Farwell’s injuries were a calculable risk of employment rather than a legal wrong. Shaw reasoned thus after adducing that the plaintiff and defendant were sui juris – self-ruling – and therefore equally competent to identify existing occupational hazards and to  allocate the associated costs between them. The chief justice concluded that Farwell had voluntarily assumed the risks of employment. Accordingly, the court ruled that considerations of “justice” and “policy” prohibited the extension of employers’ liability. This opinion, which had established employers’ non-liability at law, was precedent setting in Massachusetts and in jurisdictions throughout the nation.49 Although Shaw had not expressly addressed workers’ right of person, he had done so implicitly by figuring embodied labour as a good of fluctuating value.50 This representation flew in the face of medical wisdom and the terms of hygienic citizenship. Shaw had dared to suggest that the laws of health were subject to modification by market forces. Moreover, the chief justice had quashed workingmen’s assertion that bodily integrity, defence, and autonomy were essential to self-possession. According to Shaw, independence originated in the right of contract rather than the liberty of person. Workers’ sale of control over their bodies was not, therefore, a threat to free will. Shaw’s reasoning was not without contradiction. On the one hand, he had recognized workers’ property right in their labour. On the other hand, he had denied wage earners’ claim to damages when their bodies were harmed at work. Disabling and fatal occupational injuries were, then, a private misery to be borne by workingmen and their dependents. Now stripped of their right of action, injured workers bereft of  family support turned to public aid and endured the humiliations of dependency. The Bay State’s debilitated wage earners could expect scant public support. Federally sponsored and state-sponsored relief of any significance

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was extended solely in cases of large-scale disaster, and this aid was neither automatic nor customary.51 Only poor relief held out the promise of aid to injured workers. As with English poor law (examined elsewhere in this volume by Marjorie Levine-Clark), Bay State public relief upheld the male family wage, characterized unmarried women as dependents, and scorned the able-bodied poor.52 In short, and as Levine-Clark argues for the English system, the Commonwealth’s poor laws reflected and sustained customary gender relations.53 Indoor relief became the norm in this period, with the result that almshouses, workhouses, and homes for the insane and blind dotted the state’s landscape.54 Working people entered these institutions at peril to their social and civic identities, yet resistance to taking relief threatened one’s health status. Poverty was a contributing factor to ill health, which in turn thwarted wage earners’ quest for economic selfsufficiency.55 Workers caught in this downward spiral were censured and marginalized. By 1850, then, the state’s workforce inhabited a world in which the ethos and operations of industrial capitalism had all but eclipsed the traditional “moral economy” of exchange and labour.56 As a result, two questions now confronted wage earners. Would they heed the laws of health at the expense of income, or would they bend their bodies to the workings of the marketplace to secure their livelihood? This was a Hobson’s choice by any measure, one that underscores how health was constituted by evolving modes and relations of production. No matter how workingmen chose, their independence was compromised.

Bodies and Mammon The contradictory imperatives of health and the marketplace bedevilled workingmen on the state’s first railways, including those employed by the Boston & Worcester Railroad. The corporation commenced ­operations on 16 April 1834, but its board of directors had instituted few, if any, safety measures before selling their first tickets. Instead, they made up rules and procedures as circumstances dictated. Because the corporation took a patchwork approach to accident abatement, collisions between man and machine were frequent and lethal.57 Railroad employees managed occupational hazards in the context of  changing labour relations. The industry’s unprecedented scale of ­operations yielded new organizational structures and innovations in the management of work and employees. These changes transformed

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customary relations between master and servant. Employer and employee no longer toiled in close proximity; instead, the master disappeared altogether, replaced by “the legal entity of the corporation.” Supervisors now managed geographically and organizationally dispersed operations. Moreover, employees separated by space and hierarchy had scant knowledge of the dangers posed by incompetent co-workers – as was the case with Farwell – or defective machinery.58 These circumstances belied Chief Justice Shaw’s assertion that employers and employees were equally capable of identifying and allocating the risks of an occupation.59 The frequency of accidents on the Boston & Worcester Railroad illuminates the insufficiency of directors’ approach to hazard control. From 1834 to 1843 more than 30 serious accidents occurred, and it is likely that many more were unrecorded.60 Board minutes indicate that employees were far more likely than passengers to be injured or killed in collisions.61 Consequently, employee accidents were a staple agenda item at meetings of the directors and stockholders.62 The board’s compensation of injured employees was equally deficient, owing to its preoccupation with status relations, aversion to a­ ssuming responsibility for industry hazards, and dependence on stockholders. Because the directors conceived of workingmen as social inferiors, noblesse oblige inspired the railway’s response to their injuries. Corporate paternalism was counterbalanced, however, by the directors’ unwillingness to incur (or appear to incur) absolute liability for employee injuries. Furthermore, the board managed its expenditures, i­ncluding employee indemnification, with an eye to stockholder confidence.63 Board members harmonized these opposing obligations by compensating injured workingmen for immediate, rather than long-term, losses. The former included medical expenses, damaged property, and wages lost during treatment. From 1834 to 1843, the corporation bestowed an average of $100 per injured employee, with compensation rarely exceeding $200.64 These indemnities fell well below the railway’s court-ordered settlement with injured contract employee Gilham Barnes, who in 1839 received $3,000 in damages and $435.99 for medical care.65 Comparable payments would not be forthcoming after 1842, the year that the Massachusetts judiciary insulated employers from injured workers’ suits for damages. Occasionally the directors approved larger sums for favoured employees and their dependents, as was true of the widow and children of Hiram Bridges. Bridges was an engineman described by directors as ­surpassingly honest. After his death in 1838, the board awarded $500 to

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widow Bridges, to be paid “in such manner as … [is] best-calculated to afford relief, comfort, & support” to her family.66 The Bridges case and others like it indicate that corporate evaluations of employee worthiness favoured superintendents and skilled workers, as befit directors’ attentiveness to status. This preoccupation with employees’ station – as opposed to their rights as men – contributed to the railway’s differential valuing of working bodies. For example, on 13 April 1839, the directors memorialized the recent death of superintendent James F. Curtis. The board lauded Curtis as a man of “estimable character” who had discharged his duties with “intelligence, assiduity, fidelity & efficiency.” Having declared Curtis a paragon of manliness, the board directed its president to tender a bequest to the next of kin personally.67 By comparison, the board rarely approved allocations to employees of lesser status without thoroughly investigating the merits of the case. The directors instructed their agents to interview claimants and make recommendations concerning indemnification. At no time did the board frame its beneficence in terms that implied absolute liability for industry perils.68 The board’s minutes are an invaluable lens on employers’ valuations of labouring bodies, but these texts are silent on the cost of industrial accidents for workers and their families. For this we may look to plaintiff testimony in Barnes v. Boston & Worcester Railroad (1839). Gilham Barnes filed suit in 1837 after sustaining disabling injuries during the derailment of the gravel train on which he rode.69 Case records report that a train “wheel broke, and the cars were thrown from the track.” Barnes’ arm was broken and subsequently amputated, rendering him unfit for labour in his family’s tarring business.70 Against the advice of his physician, who had interceded with the railroad on his patient’s behalf, Barnes refused to petition the railroad for compensation. Instead, he exercised his legal right of action, thus treating with his employer as a citizen rather than as a supplicant.71 Witnesses for the plaintiff stated that more was at stake for Barnes than his present or future earnings. Family friend Abigail Whitney testified that he “was hurt bad & … nothing could make up the loss to his family.” Simply put, Barnes’ injuries had shattered his family’s security. Whitney also condemned the railroad’s “wicked[ness]” in “suffering” its  employees to ride defective machinery, thus underscoring the cor­ poration’s subordination of its workforce. Unlike Whitney, Owen G. Mansfield attested to the cost for Barnes of incapacitation. Mansfield, a one-time employee of Barnes, testified that his former employer had

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been “very active and smart” and could “do double [the work] of others” owing to his “great quickness.”72 Where previously Barnes had enjoyed unparalleled brawn and speed, he was now unmanned, or so Mansfield implied. In 1837, the Suffolk County Court of Common Pleas ignored the witnesses’ characterizations of Barnes’ losses and found for the railroad.73 The plaintiff appealed the judgment, whereupon the parties agreed to submit the dispute to court-appointed referees. On 18 April 1839, the panel found for Barnes after concluding that the railroad had not exercised due care in the maintenance of its gravel train.74 In this instance judicial authority had upheld workers’ right of person and secured Gilham Barnes against the impoverishment that often befell injured wage earners. But as we have seen, in 1842 the Supreme Judicial Court of Massachusetts reversed Barnes in Farwell, thereby establishing employers’ non-liability at law. Thence workingmen would mobilize for statutory reform of judge-made law that had denied them the rights of corporeal citizenship.

H e a lt h : P r o p e rt y a n d a S tat e o f G r ac e Whereas plaintiff testimony in the Barnes case subordinated social criticism of industrial accidents to the narration of Barnes’ losses, workers’ arguments for the ten-hour day drew explicit links between the health status of wage earners and that of the nation. Anglo-American law, republican ideology, and Christianity provided the scaffolding for workingmen’s reasoning. Hence, they defended their person by invoking principles advanced in the 1760s by the English jurist Sir William Blackstone in Commentaries on the Laws of England. Blackstone’s codifi­ cation of English law – the first of its kind – continued to influence American legal and political reasoning into the 1860s.75 Accordingly, labourers were schooled in Blackstone’s assertion that man had a right to the “uninterrupted enjoyment of his life, his limbs, his body, his health, and his reputation.”76 The republican corollary to this idea had it that national civic virtue derived from a self-governing citizenry. Thus, the economic dependence of wage earners on their employers and their consequent vulnerability to political manipulation made them anathema to the republic.77 In 1834, Seth Luther – a Christian, carpenter, and co-founder of the Trades Union of Boston – voiced these ideas while seeking to galvanize the labouring men seated before him, for they were, he argued, the

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nation’s bone and sinew. Delegates to the Union Association of Workingmen listened as Luther extended his metaphor by characterizing an injury to producers as an injury to the republic. Speaker and audience were steeped in the argument that producers “simultaneously created and advanced” human progress. They did so by virtue of “the transformations their labour worked upon the earth’s resources and face.” This shared worldview enabled Luther to appeal to his listeners’ pride and patriotism as he urged them to secure their persons and interests in the workplace.78 Luther elaborated on the idea that manly independence was God given and “a matter of flesh and blood” in his 1836 address to workingmen in Brooklyn, New York.79 The fiery orator sought to persuade his audience that avaricious employers had created “emporiums of human misery” in which workers had “no more control over their own movements than the lifeless machinery has.”80 (Three years later, Dr Benjamin McCready would make a comparable argument.) Luther advocated resistance and urged those present to emulate Thomas Jefferson, the American revolutionary who had “sworn … eternal hatred to every form of tyranny.” Should Luther’s listeners shrink from rebellion, he assured them that God, “the great Lawgiver of the universe requires none of his creatures to respect injustice.”81 Luther’s argument was both a denunciation of the rigours of industrial capitalism and a commentary on employers’ dominion over workingmen’s minds and bodies, itself the product of asymmetries of power in the labour contract. Luther concluded that if wage earners were to secure their independence, thereby preserving the nation, they must resist their social and bodily subjugation by employers. One year earlier, the Boston carpenter had gathered with other east coast artisans in New York City to settle their arguments for the ten-hour day and then petition Congress.82 Labour delegates denounced the rigours of their work in a widely distributed circular, in which they condemned the thirteen- and fourteen-hour days that visited ruination on their bodies and minds. Workingmen were so exhausted, or so the circular reported, that they had “no desire but to eat and sleep.” The costs for workers were “weakness, loss of health, and even life.”83 According to those gathered in New York, these conditions were “a perversion of the [US] constitution … which guarantees every citizen the protection of ‘life, liberty, or property.’”84 Seth Luther and other workingmen found inspiration not just in law but also in scriptural teachings, as seen by Luther’s assertion that

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healthfulness was analogous to a state of grace. Thus Luther proclaimed labour’s motto to be “Vox Populi, Vox Dei – the voice of the people is the voice of God.” He argued further that Christians had a duty to challenge inequalities in the wage relation “so that true religion might prevail.”85 Likewise, he asserted that unhealthy working conditions were an affront to the creator. As he explained it, “God of the Universe has given us time, health and strength. We utterly deny the right of any man to dictate how much of it we shall sell.”86 As Luther saw it, God’s law and that of civilized men would always privilege workers’ health and right of person over employers’ property rights in embodied labour. Luther also invoked revolutionary Americans’ commitment to secure both liberty and “material sufficiency” for all citizens. Fulfillment of this compact depended on harmonizing the preconditions of male autonomy and the requirements of the market. How citizens laboured – whether with fullness of self, in good or ill health, and for more than a subsistence wage – would mark the upholding or invalidating of this contract.87 While workingmen such as Luther emphasized the costs for them of unwholesome working conditions, they also addressed the effects of these on their capacity for civic engagement. The authors of the Ten Hour Circular reckoned that producers had “rights and … duties to perform as American Citizens and members of society.” Their discharge of these gendered obligations was impossible when the workday exceeded ten hours.88

The Gendering of Health and Personhood Luther’s arguments emerge in bold relief when compared with critiques of industrial capitalism advanced by Lowell’s female textile operatives. In their petitions for maximum hours legislation, mill workers described themselves as “peaceable, industrious, [and] hard working.” Having declared themselves credible, the operatives reported that they were “confined ‘from thirteen to fourteen hours per day in unhealthy apartments.’” As a result, they were “hastening through pain, disease and privation … to a premature grave.” Needed, they argued, was a ten-hour day that would reduce their susceptibility to illness, the result of “long hours of labor, the shortness of time for meals, and the bad air of the mills,” otherwise they would remain a “slave to the caprices of him for whom she labors.”89

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Sarah Bagley, a weaver, also denounced the infringement of her person by textile production, but she did so in terms that emphasized women’s domestic duties. Bagley acidly remarked, “At one time, they tell us that our ‘free institutions’ are based upon the virtue and intelligence of the American people, and [that] the influence of the mother form[s] and mould[s] the man – and [in] the next breath, that the way to make the mothers of the next generation virtuous, is to inclose them within the brick walls of a cotton mill from twelve and a half to thirteen and a half hours a day.”90 Bagley’s statements illumined both the gendered dimension of women’s labours and female operatives’ particular disadvantage in conflicts with employers. Owing to custom and law, women workers had neither the social nor the political capital to counter their exploitation by employers. Indeed, Bagley left millwork upon concluding that her unhygienic working conditions had caused her ill health. In 1844, Bagley and others sought to strengthen their hand by establishing the Lowell Female Labor Reform Association, an affiliate of the New England Workingmen’s Association. Its members dedicated themselves to winning higher wages, better working conditions, and other reforms.91 According to antebellum gender norms, women such as Bagley could achieve health and respectability without being independent, whereas the independence and respectability of freeborn men was contingent on their health status and able-bodiedness. Incapacitated workingmen were anomalous, therefore, in a slave republic that correlated masculine sovereignty with self-governance. Not only did employers determine the instrumentality of male wage earners, but workingmen were vulnerable to disabling occupational accidents and diseases. When viewed within the context of the wage relation, workingmen were demonstrably unable to exert control over their bodies. Producers lacking in bodily agency were singularly grotesque because they were equivalent to “others” having no title to their bodies, including women and slaves. Worse still, many elites, including medical authorities, regarded workers as the authors of their own infirmities.

Conclusion Wage-earning men who conjoined health and selfhood drew selectively on medical wisdom to argue for the right of person. On the one hand, they embraced the prevailing idea that body and mind were

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interde­pendent elements constituting a single organism. Thus, mental and physical equipoise engendered well-being, whereas systemic imbalance resulted in illness. Mill worker Harriet Farley sustained these ideas when she attributed the suicides of two textile workers to their disequilibrium of body and spirit.92 On the other hand, labouring men discredited medical theorizing in two ways. First, they invalidated the idea that health was a matter of choice, not circumstance, by making the conditions of labour susceptible to public scrutiny. Second, American workers who willingly made a spectacle of their imperilled bodies – at a cost to their social and civic identities – challenged employers’ denial of employees’ physical and mental well-being. By so doing, male workers and their female counterparts sowed the seeds of ideas that underlay future labour reforms such as protective legislation for women workers and workmen’s compensation. Ultimately, antebellum workingmen sought to harmonize the laws of health with the terms of labour to secure their social and civic status as sovereign men. They did so by reinterpreting the principles of health and the terms of the employment contract. They vigorously argued that the authority of capital over labour was provisional rather than absolute. Wage earners had a right, they reasoned, to sell their productive capacities without ceding authority over their person. Left unanswered, however, was a crucial question: Where would the line be drawn between employers’ property rights in labour and workers’ liberty of person?93 Even as male labourers began to contest the law of employment, employers such as the Boston & Worcester Railroad had begun to fix the price of workers’ bodies and injuries. Directors of the railway gave no quarter to arguments for the sanctity of health or its irreducibility to market calculations. Nor did they credit the idea that national virtue rose and fell with the health status of the American worker. Instead, the board of directors indemnified workers with a view to limiting its own liability and maintaining shareholder dividends. Consequently, p ­ aternalist expressions of regard and sympathy for injured employees succeeded only in glossing over the railway’s devaluation of their pain and suffering. Later generations of workingmen in the northeastern United States would also assert their claim to the rights of health, bodily defence, and autonomy. Like their predecessors, their assertions of these fundamental rights of citizenship would be entwined with their concern for masculine sovereignty. Their belief that health was foundational to one’s status as head of household and citizen would inform their campaign rhetoric and strategies. At stake for labouring men was the

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question of whether they or the relations and conditions of industrial capitalism would continue to “shape – literally and figuratively – the working-class body.”94

Acknowledgments I thank the editors of this volume for their incisive comments and encouragement to deepen my reasoning. Thanks also to my co-­ ­ participants in the Symposium on Gender and Health in History in the 19th and 20th Centuries (11–13 May 2011). Their breadth of knowledge inspired me.

notes   1  I concur with Nikolas Rose and Carlos Novas, who have argued that citizenship has “long had a biological dimension” that “underpinned distinctions between actual, potential, troublesome, and impossible citizens.” The authors conclude that these divisions (and the ideas that engendered them) constitute “biological citizenship.” While I am indebted to this argument, I prefer the descriptor corporeal citizenship for two reasons. First, it is synchronous with antebellum knowledge about the natural ­sciences and physiology. Second, the phrase corporeal citizenship encapsulates workingmen’s concerns with the form, materiality, and capacities of the labouring body. Rose and Novas, “Biological Citizenship,” 440, 446, 458.  2 Keyssar, The Right to Vote, Table A.2. State lawmakers had eliminated property requirements for male suffrage but instituted tax payments as an eligibility requirement. Ibid., 29.   3  My reasoning is informed by Bill Hughes’ analysis of varying character­ izations of the disabled by proponents of the social model. Hughes, “Wounded / monstrous / abject,” 400–2. Alan Hyde makes the related argument that the defective body may command “the empathy or sympathy,” but it also “bear[s] the legible signs that … call for its expulsion from ­society.” Hyde, Bodies of Law, 9.   4  I will use the term industrial accident as a convenience although it naturalizes the existence and effects of occupational hazards. On the historical meanings of the term accident see Figlio, “What is an Accident,” 180–206.   5  See for example, Tomlins, “A Mysterious Power,” 375–438; Weinstein, “Big Business and the Origins of Workmen’s Compensation,” 156–74; Asher, “Workmen’s Compensation in the United States”; Nelson, “The Origins of

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the Two Channel Welfare State.” More recently, John Fabian Witt has illuminated the contradictions in legal reasoning and “free labor thinking” that ran through political discourse about industrial accidents. He concludes that policy-makers sought to remedy these inconsistencies by rationalizing the compensation of injured workers. Witt, The Accidental Republic. A complementary literature has historicized the proletarianization of the antebellum workplace and its costs for wage earners. On this, Wilentz, Chants Democratic; Rice, Minding the Machine. Unsurprisingly, w ­ orkers’ bodies are integral to historical analyses of disability and occu­pational medicine. Scholars in disability studies have interpreted the meanings affixed to physical and cognitive impairment. Historians of occupational medicine, in turn, have analyzed the interplay between public health, on the one hand, and the effects on the American populace of “immigration, industrialization, and urbanization.” See, for example, Baynton, “Defectives in the Land,” 31–44; Rosner and Markowitz, Dying for Work, passim and ix, 115–6.  6 Canning, Gender History in Practice, 168. Ava Baron has argued persuasively for this analytical approach in “Masculinity, the Embodied Male Worker,” 143–60.   7  I thank an anonymous reader for the observation that bodies are “inscribed” by concepts of “manliness and citizenship.”   8  Canning, “The Body as Method,” 500.   9  John O. Green, M D , M M S S , The Factory in Its Hygienic Relation: An Address Delivered at Boston, at the Annual Meeting of the Massachusetts Medical Society, May 27, 1846 (Boston, M A : Wm. S. Damrell, 1846), 6–7. According to Green, hygienic and moral principles were interrelated. Ibid., 13. I have paraphrased Patrick Gray’s discussion of British fears about the destabilization of the nation’s moral centre by the factory system. Gray, “The Languages of Factory Reform in Britain,” 143–4. 10 Pateman, The Sexual Contract, 150–1. Pateman concludes, “to obtain the right to the use of another is to be a (civil) master. To sell command over the use of oneself for a specified time … is to be an unfree labourer,” 151. 11  Canning, “The Body as Method,” 500. 12  John Fabian Witt has argued that the preponderance “of accidents ended in death” owing to the “relatively primitive” medical therapeutics. This changed once the “germ theory [had] revolutionized the practice of medicine.” Witt, “From Loss of Services to Loss of Support,” 731. See also Bale, “America’s First Compensation Crisis,” 41. 13  These statements echo a comparable argument by John Fabian Witt. Witt, “From Loss of Services to Loss of Support,” 749.

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14  Reeve, “Social and Legal Representations of Imperiled Workers,” 12–48. 15 Siracusa, A Mechanical People, 19; Sokoloff and Villaflor, “The Market for Manufacturing Workers,” 31–2. 16  On metropolitan industrialization, see Wilentz, Chants Democratic, 107–42. 17 Dalzell, Enterprising Elite, 3; also cited in Tomlins, Law, Labour, and Ideology, 266. 18  Witt, “From Loss of Services to Loss of Support,” 719, 722. 19  C.G. Loring Case Notes, vol. 15, 1839. Case Notes for Barnes v. Boston & Worcester Railroad Corp. (1839). Social Law Library. Boston, Massachusetts. Charles G. Loring Papers. Case Notes for Nicholas Farwell v. Boston & Worcester Railroad Corp. Suffolk ss S J C . March 1842. 45 Mass (4 Metc) 49. File #E1, Social Law Library. 20  The terms servant and employee are used interchangeably in conformance with antebellum usage. 21  Barnes v. Boston & Worcester Railroad (1839); and Farwell v. Boston & Worcester Railroad, Massachusetts Reports 45 Mass 49 (S J C 1842), 49–50; and An Act Relative to Payments to Employees for Personal Injuries Received in the Course of their Employment and to the Prevention of Such Injuries, Chapter 751, Laws and Resolves, 1911. Christopher L. Tomlins has analyzed Barnes’ suit in Law, Labor, and Ideology, 299–303 and 331–46. 22  Seth Luther, et al., “Ten Hour Circular,” in A Documentary History of American Industrial Society, vol. 6, edited by John R. Commons (New York: Russell and Russell, 1958), 94–9. Factory Tracts. Factory Life As It Is, by an Operative (Lowell, M A : Lowell Female Labour Reform Association, 1845), excerpted in “We Call on You to Deliver Us from the Tyrant’s Chain”: Lowell Women Workers Campaign for a Ten Hour Workday, http://historymatters. gmu.edu/d/6217/ (­ accessed 10 July 2011). Numerous historians have chronicled the Ten Hour movement. See for example, Murphy, Ten Hours’ Labor. 23  Elisha A. Bartlett, M D , Obedience to the Laws of Health, a Moral Duty. A Lecture Delivered before the American Physiological Society, January 30, 1838 (Boston, M A : Julius A. Noble, 1838), 8, 16–17. Dartmouth College Library, New Hampshire. 24  Horrocks, “Promoting Good Health in the Age of Reform,” 262–4. In 1838, the Reverend Abel G. Duncan of Hanover, Massachusetts, observed that “a person can hardly enter” a common carrier “or railroad car, or sit down at the dining table of our hotels, without hearing some sage remarks” about the requirements of health. Rev. Abel G. Duncan, Evils of Violating the Laws of Health, and the Remedy: an Address Delivered before the American Physiological

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Society, at Their Monthly Meeting, February 7, 1838 (Boston, M A : Marsh, Capen & Lyon, 1838), 6. Verbrugge, Able-Bodied Womanhood, 26. 25  Charles E. Rosenberg has argued that physicians and their patients considered the body and mind to be interdependent both functionally and in terms of their well-being. This idea “allowed … the multidimensional ­integration of emotions, family and business circumstances, and individual habits into etiology and therapeutics.” Charles E. Rosenberg, “Body and Mind in Nineteenth-Century Medicine: Some Clinical Origins of the Neurosis Construct,” Bulletin of the History of Medicine 63, no. 2 (Summer 1989): 187–190. See also John R. Betts, “Mind and Body in Early American Thought,” The Journal of American History 54, no. 4 (March 1968): passim. 26 Verbrugge, Able-Bodied Womanhood, 25. These ideas have had remarkable staying power in American culture, as seen by Robert Crawford’s study of the 1970s self-care movement, which he terms healthism. He defines healthism “as the preoccupation with personal health as a primary … ­focus for the definition and achievement of well-being.” He observes, “Healthists will acknowledge … that health problems may originate outside the individual … but since these problems are also behavioral, solutions are seen to lie within the realm of individual choice.” The use of the term healthism is inapplicable to antebellum medical ideology given the origins of the 1970s self-care movement in the decade’s social, economic, and political cross-currents. It is noteworthy, however, that both Verbrugge and Crawford link the development of health reform movements to external threats to established relations, institutions, and ideas. Robert Crawford, “Healthism and the Medicalization of Everyday Life,” International Journal of Health Services 10 (November 1980): 368, 377, 379. 27 Verbrugge, Able-Bodied Womanhood, 26. 28  For more on Shaw’s reasoning in Farwell and its effects on workingmen, see Reeve, “Social and Legal Representations of Imperiled Workers,” 73–112. 29  Halttunen, “Humanitarianism and the Pornography of Pain,” 304. On the historical origins and evolution of western humanitarianism, see Ibid, passim. 30  Clark, “The Sacred Rights of the Weak,” 463, 475, 484. 31  Verbrugge makes the related argument that “antebellum health reform simply extended the prevailing cultural theme of self-reliance from religion and politics into the physical domain.” Verbrugge, Able-Bodied Womanhood, 26.

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32  According to woman’s rights leader Susan B. Anthony, the law of coverture “made [women], if married, in the eye of the law, civilly dead.” Declaration of Sentiments and Resolutions, Elizabeth Cady Stanton and Susan B. Anthony Papers Project, http://ecssba.rutgers.edu/docs/seneca. html#senf4 (accessed 1 August 2011). 33  Emphasis by Robert Crawford, who makes a comparable argument about the limits of healthism. Crawford, “Healthism and the Medicalization of Everyday Life,” 385. 34  Benjamin W. McCready, M D , On the Influence of Trades, Professions, and Occupations in the United States, in the Production of Disease (New York: Arno Press & New York Times, 1972), 91–150. The New York Society’s interest in occupational health undoubtedly reflected the acclaim and anxiety engendered by the English study published by the physician C. Turner Thackrah in 1831. Thackrah’s treatise, together with The Sadler Report, issued in 1832 by the House of Commons, aroused Parliament to enact the Factory Act of 1833. Charles Turner Thackrah, The Effects of the Principal Arts, Trades, and Professions, and of Civic States and Habits of Living, on Health (London: Longman, Rees, Orme, Brown, & Green, 1831); The Sadler Report, Report from the Committee on the Bill to Regulate the Labour of Children in the Mills and Factories of the United Kingdom (London: The House of Commons, 1832). 35 McCready, On the Influence of Trades, Professions, and Occupations, 6–8, 11, 33, 123–5. 36  Ibid., 125, 128–9. 37  I am indebted to Wendy Mitchinson for this insight. 38  Emphasis is mine. Ibid., 39–49. 39  Germ Theory. Contagion: Historical Views of Diseases and Epidemics. Harvard University, http://ocp.hul.harvard.edu/contagion/germtheory.html (accessed 1 March 2012). 40  Josiah Curtis, M D , “Public Hygiene of Massachusetts; but More Particularly of the Cities of Boston and Lowell,” American Medical Association Transactions 2 (1849): 515–9. 41  Emphases in originals. Bartlett, M D , Obedience to the Laws of Health, 20–22; “Address of Cyrus M. Burleigh, Esq,” American Vegetarian and Health Journal 1 (1851): 172. 42  Bartlett served as the first mayor of Lowell, from 1836 to 1838. A Brief Memoir of Dr Elisha Bartlett: With Selections from his Writings and a Bibliography of the Same (Providence: Sidney B. Rider, 1878), 7. Former mill girl Harriet Hanson Robinson recollected the strike in her memoir, written 62 years later. Harriet Hanson Robinson, Loom and Spindle or Life

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Among the Early Mill Girls (New York, T.Y. Crowell, 1898), 83–6, reproduced at History Matters, http://historymatters.gmu.edu/d/5714 ­(accessed 12 July 2011). 43 Rosenkrantz, Public Health and the State, 16–17, 21–23; Lemuel Shattuck, “Report of the Joint Special Committee … to Consider the Expediency of Modifying the Laws Relating to the Registration of Births, Marriages, and Deaths,” Massachusetts House Documents 1849, no. 65 (3 March 1849), 8–9; quoted in Rosenkrantz, Public Health and the State, 23, 39. 44  Ibid., 16–7, 21–3; Shattuck, “Report of the Joint Special Committee,” 8–9, quoted in Rosenkrantz, Public Health and the State, 23, 39. Yet again, the antecedents of twentieth-century healthism are evident in Shattuck’s reasoning. Like 1970s health reformers, Shattuck sought to promote individual healthfulness by “restructuring” American ideas and behaviours and by calling for intervention by health practitioners and the state. Crawford, “Healthism and the Medicalization of Everyday Life,” 375. 45  Reeve, “Social and Legal Representations of Imperiled Workers,” 27–30. 46  Ibid, 54; Bartlett, Obedience to the Laws of Health, 13–15. On the constituent elements of respectable manhood and womanhood, see Kann, On the Man Question. 47  Janet Zandy influences my thinking. Zandy, Hands, 12. 48  Catharine E. Beecher, Physiology and Calisthenics for Schools and Families (New York: Harper & Brothers, 1856), 172 (emphasis in original), quoted in Verbrugge, Able-Bodied Womanhood, 28, 68, 207. 49  Farwell v. Boston and Worcester Railroad, 45 Mass. (4 Met.) 49 (1842). 50  It is unsurprising that Shaw did not discuss Farwell’s corporeality in explicit terms. The body was just then coming into existence as a subject of legal analysis. According to Alan Hyde, in the early nineteenth century, “a distinctively modern body [took] shape in legal and popular culture, a body that represent[ed] an individuated, human spirit that is the person inside it, a person that control[ed] that body but [was] not identical to it.” Hyde, Bodies of Law, 9. 51  Landis, “Let Me Next Time Be ‘Tried by Fire,’” 967. As I have argued elsewhere, Massachusetts citizens were prepared to aid disaster victims, including survivors of industrial catastrophes, so long as the relief applicants could be cast as worthy and “noble sufferers.” Reeve, “Social and Legal Representations of Imperiled Workers,” 138–9. 52  Quigley, “Rumblings of Reform,” 740. The most complete analysis of the Massachusetts poor laws and relief is Robert W. Kelso, The History of Public Poor Relief in Massachusetts, 1620–1920 (Cambridge, M A : The Riverside Press, 1922).

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53  See chapter 2 by Marjorie Levine-Clark in this volume. 54  Quigley, “Rumblings of Reform,” 756–7. 55  See chapter 2 by Marjorie Levine-Clark in this volume. 56  To quote E.P. Thompson, a moral economy encompasses “a traditional view of social norms and obligations”, including ideas about “the proper economic functions [and conduct] of … parties within the community.” Thompson, “The Moral Economy of the Eighteenth Century,” 79. 57  The General Court of Massachusetts chartered the Boston & Worcester on 23 June 1831. Salsbury, The State, the Investor, and the Railroad, 93, 114–115; Stockholders’ Minutes, Boston & Worcester Railroad, vols. A1 (July 1831 to February 1835); A2 (24 February 1835 to 14 November 1837); A3 (21 November 1837 to 28 December 1840); A4 (4 January 1841 to 29 March 1843), Baker Library, Harvard University. 58  These points are informed by Stanfield, “Through the Eyes of the Gavel,” 8–10. 59  Reeve, “Social and Legal Representations of Imperiled Workers,” 105. 60  My calculations of accidents derive from my reading of the minutes of the directors and stockholders for 15 March 1834 to 20 February 1843. These minutes are incomplete because railway agents failed to report every accident and made settlements with the injured party without consulting the directors. In 1841, corporation officers put a stop to this practice upon discovering it; the practice may have continued unbeknownst to the ­officers. Stockholders’ Minutes, Boston & Worcester Railroad, vols. A1 (July 1831 to February 1835); A2 (24 February 1835 to 14 November 1837); A3 (21 November 1837 to 28 December 1840); and A4 (4 January 1841 to 29 March 1843), and especially minutes for the directors’ meeting on 25 January and 21 February 1841, vol. A4, 7–8 and 142–3, Baker Library, Harvard University. 61  Stockholders’ Minutes, Boston & Worcester Railroad, vols. A1 (July 1831 to February 1835); A2 (24 February 1835 to 14 November 1837); A3 (21 November 1837 to 28 December 1840); and A4 (4 January 1841 to 29 March 1843), Baker Library, Harvard University. 62  My research contradicts conclusions by Stephen Salsbury, who argues that major accidents were rare during the first few years that the Boston & Worcester was in operation. Salsbury, The State, the Investor, and the Railroad, 183. I tabulated railway accidents and fatalities on the basis of my reading of the stockholders’ minutes for the years 1831 through 1843. Stockholders’ Minutes, Boston & Worcester Railroad, vols. A1 (July 1831 to February 1835); A2 (24 February 1835 to 14 November 1837); A3 (21 November

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1837 to 28 December 1840); and A4 (4 January 1841 to 29 March 1843), Baker Library, Harvard University. 63  Reeve, “Social and Legal Representations of Imperiled Workers,” 60–1. 64  From 1834 to 1843, the corporation settled with more than thirty petitioners and litigants. Directors’ and Stockholders’ Minutes, Boston & Worcester Railroad, vol. A1, July 1831 to February 1835, 89, 162–3, 254; vol. A2, 24 February 1835 to 14 November 1837, 239–40, 264; vol. A3, 21 November 1837 to 28 December 1840, 2, 12, 14–5, 47–8, 75, 89, 95, 101, 119, 120–1, 201–2, 213–4, 217; vol. A4, 4 January 1841 to 29 March 1843, 7–8, 12, 17, 41, 72–3, 103–4, 114–8 123–4, 142–3, 158, 161, 173–4, 177–8, 191, 211–2, 221, 238, 262, 250–2, 256, 258–9, Baker Library, Harvard University. 65  Supreme Judicial Court. Suffolk County, Docket Books, March 1839, no page. The sum of $100 is equivalent in 2010 dollars to approximately $2,835, while $200 is equivalent to approximately $5,665. Purchasing Power of the United States Dollar, 1774 to Present. How Much Is That? EH-Net, http://eh.net/howmuchisthat/ (accessed 25 July 2011). 66  Directors’ and Stockholders’ Minutes, vol. A3, 21 November 1837 to 28 December 1840, 75, Baker Library, Harvard University. 67  Ibid., 120–1. See also two additional cases of this type. Ibid., 213, 217–8 68  The minutes indicate that the directors understood settlements as “grants,” “charity,” and “relief” rather than as recompense. Directors’ Meeting, 15 July 1833, vol. 1 of Minutes, 163, Baker Library, Harvard University. 69  Barnes v. Boston & Worcester Railroad, Court of Common Pleas, Suffolk County, Record Book, October Term 1837, Judicial Archives, Archive of the Commonwealth. 70  It was corporate policy for the railway to maintain separate trains for conveyance of merchandise, passengers, and gravel needed to maintain the track. Testimony in the case indicates that this arrangement conformed to the differing standards of liability for common carriers and passenger carriers. Charles Greeley Loring Papers, Case Notes, vol. 15, 1839, Barnes v. Boston & Worcester Railroad Corporation, Social Law Library, Boston. 71 Ibid. 72 Ibid. 73  The lower court ruled that Barnes had forfeited his right of action by ­violating company prohibitions against riding the gravel train. My account of the lower court’s decision conflicts with that of Christopher L. Tomlins, who states that the Court of Common Pleas found for Barnes and that the railroad then appealed to the Supreme Judicial Court. Tomlins,

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“A Mysterious Power,” 377. On the basis of my research, I conclude that the corporation filed a motion for demurrer and the court sustained it. Barnes then appealed. Barnes v. Boston & Worcester Railroad Corporation (1837); and Supreme Judicial Court, Suffolk County, Records Books, March / November 1839, Barnes v. Boston & Worcester Railroad Corporation, Judicial Archives, Archives of the Commonwealth, Boston. 74  The referees’ report appears in Supreme Judicial Court, Suffolk County, Records Books, March / November 1839, Barnes v. Boston & Worcester Railroad Corporation, Judicial Archives, Archives of the Commonwealth, Boston. 75  Sir William Blackstone, Commentaries on the Laws of England in Four Books, vols. 1–4. (Oxford: Clarendon Press, 1765–69). Albert S. Miles, David L. Dagley, and Christina H. Yau, “Blackstone and his American Legacy,” Australia & New Zealand Journal of Law & Education 5, no 2. (2000): 46–59. 76  Sir William Blackstone, Chapter 1, “Of the Absolute Rights of Individuals,” Commentaries on the Laws of England in Four Books, vol. 1 (1753), 129, http:// oll.libertyfund.org/index.php?option=com_staticxt&staticfile=show. php%3Ftitle=2140&layout=html (accessed 20 August 2012). 77  Reeve, “Social and Legal Representations of Imperiled Workers,” 26–7. 78  My reading of Gregory L. Kaster’s analysis of the “accents” and “actions” of working-class manliness has enabled me to posit this argument. Kaster, “Labour’s True Man,” 24–64. Malloy, Gersuny, and Macieski, Peaceably if We Can, Forcibly if We Must, 21–2; Kaster, “We Will Not Be Slaves to Avarice,” 17–19, 46. 79  E. Anthony Rotundo has argued, albeit not decisively, that middle-class conceptions of manliness evolved during the nineteenth century. He contends that the earlier emphasis on character and free will gave way to concern for masculine virility. Arguments by antebellum workingmen support Rotundo’s reasoning. Rotundo, “Body and Soul,” 23–38, especially 29. 80  Seth Luther, An Address Delivered before the Mechanics and Working-Men, of the City of Brooklyn, on the Celebration of the Sixtieth Anniversary of American Independence, July 4, 1836 (Brooklyn, N Y : Alden Spooner and Sons, 1836); Luther, An Address on the Origin and Progress of Avarice, and Its Deleterious Effects on Human Happiness with a Proposed Remedy for the Countless Evils Resulting from an Inordinate Desire for Wealth (Boston, MA: Seth Luther, 1834). 81  Inductee Details: Seth Luther, Rhode Island Heritage Hall of Fame. http://www.riheritagehalloffame.org/inductees_detail.cfm?iid=512 ­(accessed 21 July 2011); Luther, An Address Delivered to the Mechanics and Working-Men of the City of Brooklyn, 9.

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82  According to David Montgomery, “the decisive battle for manhood ­suffrage was initiated in 1832–3 by regional conventions of workers, who linked their demands expressly to petitions and strikes for the ten-hour day” as well as to other desired reforms in the electoral arena. Montgomery, Citizen Worker, 18; Foner, History of the Labour Movement in the United States, 114–5. 83  The Committee, Ten Hour Circular. 84  “Proceedings from the 1835 Convention of the National Trades’ Union (New York), Oct. 1835,” in A Documentary History of American Industrial Society, vol. VI, Labor Movement, edited by John R. Commons and others (New York: Russell & Russell, 1958), 231–2, 246–7. 85  Ibid., 95. 86  The Committee, Ten Hour Circular. 87  Seth Luther, An Address on the Right of Free Suffrage (Providence: S.R. Weeden, 1833), 25, quoted in Macieski, “‘Ye Cannot Serve God and Mammon,’” 93, 95; McCoy, “Benjamin Franklin’s Vision of a Republican Political Economy for America,” 605; Tomlins, “A Mysterious Power,” 381. 88 Luther, An Address on the Right of Free Suffrage, 25. 89  Thousands of female mill workers and their male allies signed these ­petitions. Massachusetts House Document, no. 50, March l845, http:// courses.wcupa.edu/johnson/lowell1845.html (accessed 2 February 2012); “We Call On You to Deliver Us From the Tyrant’s Chain”: Lowell Women Workers Campaign for a Ten Hour Workday, http://historymatters. gmu.edu/d/6217/ (accessed 2 February 2012). 90  Massachusetts House Document, no. 50, March l845; Quoting Sarah Bagley: Juravich, Hartford, and Green, Commonwealth of Toil, 23; Brown and Tager, Massachusetts: A Concise History, 136. 91  Ibid., 10. 92  Farley concluded that an injury to the body “must depress and weaken the mind.” Conversely, she opined, “it is impossible that the mind should be so deeply affected without injury to the body.” Harriet Farley, “Editorial: Two Suicides,” Lowell Offering, vol. 4, 1844. http://www.learner.org/­ workshops/primarysources/lowell/docs/suicide.html (accessed 10 July 2011). 93  My reasoning is informed by Robert J. Steinfeld’s analysis of US lawmaking aimed at solving a “fundamental problem with liberal commitments to freedom,” namely, “a basic, unresolvable contradiction between commitments to liberty of person and liberty of contract.” Steinfeld, “Changing Conceptions of Free Labor,” passim and especially 150. 94  As Janet Zandy has argued, “individualism … cuts linkages” between choice and circumstances. Zandy, Hands, 12.

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2 Gendered Roles, Gendered Welfare: Health and the English Poor Law, 1871–1911 Marjorie Levine-Clark Joseph Robinson applied for poor law assistance from the relieving officer of the Stourbridge Board of Guardians on 9 July 1891. He claimed a need for relief because his wife had injured herself falling down the stairs, and he was “not able,” being too aged and infirm, to provide the extra resources and care she would need. The record of Robinson’s application indicates that he was a 68-year-old blower (he probably worked a bellows in an ironworks or was a glass blower), but it seems unlikely that he was still employed at that point. An unspecified club gave his wife Priscilla medical relief, but this was insufficient to sustain the couple. They got little help from their children: one son had just been released from prison, and another was still in jail. Robinson’s petition was successful; he was granted medical assistance as well as relief in kind, and he appeared weekly before the poor law officials to have his relief renewed.3 Ten years later, on 23 May 1901, 23-year-old Sarah Ann Parkes applied to the Stourbridge poor law authorities for relief to assist her ­infant daughter, who was suffering from an undefined illness. Her application identifies Parkes as an able-bodied labourer, working in a brickyard for three shillings and two pence a week, and as an unmarried working mother with no other resources, needing to care for an ailing daughter. She had recently left the union workhouse, presumably after having given birth there. Her appeal was granted, and she received eight pints of milk. She applied again two weeks later, and two weeks after that, and both times was given similar relief in kind. Her child died on 17 July, and the poor law guardians helped cover burial expenses.2

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54  Embodied Citizenship

William Payne of Brierley Hill, a 47-year-old married labourer with seven children under the age of sixteen, applied in April 1911 for poor law relief, suffering from rheumatism. His application lists William as able-bodied, which meant he was usually physically able to work, yet his rheumatism affected his wage-earning ability. On 20 April 1911, he was granted relief in kind and continued to receive this assistance with monthly petitions until September, when he applied three times. His wife, Mary Payne, 44, whose occupation is listed as “domestic,” applied intermittently during the same time. She came to the relieving officer because her husband had been “sent to a home to cure his rheumatism.” She, too, was granted relief in kind through August.3 These three examples of applicants for poor law assistance reflect the ways in which ill health challenged the economic solvency of a variety of  family structures in late-nineteenth- and early-twentieth-century England, leading individuals to interact with welfare providers. In the Robinsons’ case, an injury to an elderly wife was perhaps the final straw added to difficulties already created by the couple’s age and infirmity. For Sarah Parkes, a daughter’s illness put pressure on her low earnings and marginal status as a single mother. In the case of the Paynes, the male breadwinner’s ill health and eventual institutionalization compromised the economic stability of the entire household. The poor law authorities received these applicants with ideas about heads of households, primary wage earners, sexuality, and parenthood already shaped by their Victorian and Edwardian contexts. Joseph Robinson, for example, had to apply in the name of his wife; she did not petition for her own relief. Sarah Parkes came before the poor law authorities positioned outside of normative family structures: she was an unmarried woman with a child, whose particular needs were informed by her singleness and her gender. For the Paynes, it is telling that Julia became an applicant for assistance on her own only when William was absent. Employing a close analysis of cases like these, this chapter explores relationships between health and gendered social roles in the context of the late-nineteenth- and early-twentieth-century English Poor Law. The applications for poor law assistance reveal the ways in which gendered ideas about health and the body were put into practice. Sociocultural factors worked in tandem with biological assumptions about the relative capacities of men and women to shape welfare in support of a gendered vision of the state. In this vision, health had very different labour values for male and female applicants, because the

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Health and the English Poor Law  55

expectations about the ways men and women used their bodies were fundamentally different. As Nikolas Rose and Carlos Novas have argued, “specific biological presuppositions, explicitly or implicitly, have underlain many citizenship projects … [and] shaped conceptions of what it means to be a citizen.”4 This biological citizenship, as expressed in latenineteenth and early-twentieth-century poor law records, was clearly gendered. It was informed by a male breadwinner norm that positioned men as agents responsible for women and children dependants: men needed health to produce and provide; women needed health to reproduce and care.5 Men’s bodies had to be capable of gainful employment to maintain their citizenship claims: until 1918, receipt of poor law relief meant a man was stripped of his vote in England. As was true for the American workingmen Patricia Reeve describes in this collection (chapter 1), health was a significant component of masculinity and allowed men to fulfill the expectations of masculine citizenship. Masculine citizenship thus presupposed a particular labour-capable embodiment from which women were excluded. Poor health often prevents people from maintaining economic security and thus from fully participating in society. From its inception in the Elizabethan era, the English Poor Law always recognized that ill health and poverty were interconnected, and “experience and actual observation” clearly revealed “that a vast amount of pauperism was the direct and immediate result of ill-health,” as the Fabian reformers Sidney and Beatrice Webb wrote in 1910.6 The Poor Law shaped England’s only system of public support before the institution of national health insurance in 1911, and poor law relief provided a central medical resource for the poor. Health care under the Poor Law has received a good deal of attention from historians, but much of it has focused on poor law workhouses and infirmaries as sites of medical care, relationships between poor law medicine and the professionalization of general practitioners, and the huge variations in medical practice in diverse poor law unions.7 More recent poor law historiography has addressed how gender constructions influenced policy and practice, but the precise gendered nature of health in relief processes has received little study.8 An extensive literature on the history of welfare highlights the role of the state in shaping and maintaining gendered conceptions of social and economic citizenship, to which the Poor Law was an early contributor.9 This chapter addresses each of these literatures by pinpointing the ways in which, before the advent of national health insurance, a local system of welfare shaped

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56  Embodied Citizenship

and reinforced a gendered biological citizenship tied to the able (male) body’s ability to work. The records that form the basis of this study are applications for relief from the Stourbridge Poor Law Union in the Black Country of England’s West Midlands near Birmingham, about 125 miles northwest of London.10 From the 1860s, Black Country iron and coal industries battled the exhaustion of natural resources and poor demand for local products, while the region’s domestic nail and chain making went into serious decline as a result of competition from larger factories.11 This contributed to chronic under- and unemployment in areas dominated by these industries and trades, leading local inhabitants to rely heavily on the Poor Law. The Stourbridge Poor Law Union was one such area. The relief applications of this period are found in the large application and report books of the relieving officers to whom the poor applied for aid. These books contain lists of petitioners’ applications by date and include rich demographic data such as age, marital status, occupation, and the relationship of the petitioner to dependants and adult children. Relieving officers also recorded the types of relief applicants requested and the outcomes of their petitions. I constructed a database with entries for each separate application, creating columns for all sortable information available in the application (demographic details, reasons for applications, results, etc.) as well as a column for comments. My data set from the application books contains information on 4,324 separate adult applicants (what I call the initial applicants / applications), who applied a total of 7,439 times (the total applicants / applications).12 This database has facilitated quantitative and qualitative analysis of a wide variety of relationships among the categories of an application, as I examine aggregate applicant profiles as well as the stories of ­individual petitioners. Health features prominently in the applications, with about twothirds of applicants noting some kind of health-related reason for their need for relief. Sometimes, applicants asked specifically for medical relief, which the Poor Law provided through district medical officers; in other circumstances, health issues contributed to a larger welfare need that required grants of money or goods; finally, poor health might lead to a workhouse or infirmary if care could not be undertaken at home. Poor law providers made decisions about the type of relief to award to applicants, taking into account the “facts” of the applications and their own ideas about men’s and women’s bodies and needs. Petitioners made claims about health to provide evidence of their deservedness.

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Health and the English Poor Law  57

T h e P o o r L aw a n d A b l e - b o d i e d n e s s While the Poor Law had existed since late Elizabethan statutes, it underwent significant revision in 1834.13 The Poor Law Amendment Act of 1834 intended to curtail the rising local taxes (the “rates”) used to pay for poor relief under what came to be known as the Old Poor Law and to halt what was perceived as the tendency of the poor to rely on public funds rather than to develop independence and respectability through labour. Reformers attempted to abolish relief to able-bodied applicants except in a workhouse, assuming that workhouse relief was so demeaning that all who could avoid it would do so. This aim was never fully implemented for a wide variety of reasons, including impracticability because of the large numbers of people applying for aid.14 Outrelief – cash grants and in-kind aid – continued to be the norm throughout the period of my data set.15 The overall goal of the 1834 New Poor Law was to force able-bodied (male) workers into the labour market and prevent their dependence on the state. The law acknowledged that certain classes of people – the aged and the infirm, in particular – did not deserve the humiliating treatment of the workhouse and could continue to receive cash grants. Despite a growing recognition of the structural aspects of unemployment by the end of the nineteenth century, poor law authorities continued to find fault with able-bodied applicants who sought relief. Because an application based on ill health was less stigmatized than one based on non-medical reasons, it is probable that applicants used ill health to bolster their claims for assistance. In the poor law world, to be able-bodied meant to be able to work, and poor law authorities were attentive to whether or not an applicant was able to follow his or her particular occupation. Reflecting the paid employment opportunities in the Stourbridge Union, work connected to coal and iron production and nail and chain making appears frequently in the applicants’ lists of occupations. Many of these jobs were precarious, and some, such as nail making, barely afforded subsistence wages. Although welfare authorities expected the able-bodied to work, very often regular work was unavailable, and what was available was insufficiently paid. As can be expected, women predominated in domestic service and household work, making up almost 100 per cent of these occupations. Indeed, paid and unpaid domestic work made up 72 per cent of all women’s work listed in the data set.16 As central as the concept of able-bodiedness was to poor law policy and practice, it was an unstable category. The Poor Law Commission of

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1909 recognized the variability of the term, noting, “We cannot say whether a man who was classed as able-bodied fifty years ago would be so now, nor, indeed, whether a man classed as able-bodied in one Union to-day would be so classed in another.”17 According to one witness, “What is an able-bodied pauper is still in doubt. We first of all exclude those who are sick but of the remnant, how many are men who actually are able to do a day’s work and earn their own living we do not know.”18 As these passages suggest, conceptions of able-bodiedness were clearly gendered. Because wage earning and citizenship were so closely associated with men in this period, the category “able-bodied” developed specifically in reference to men and in conjunction with ideas about men’s responsibilities for supporting their families. Women, as I have argued elsewhere, were considered naturally less able-bodied because of the assumed fragility of their reproductive functions.19 Women’s vulnerability to poor health was implied in ways that men’s was not. It was above all able-bodied men whom poor law authorities sought to drive away from relief. Able-bodiedness and the male breadwinner ideal reinforced each other, producing interpretations of health that intersected with gender, age, and marital status.

Applicant Profiles To receive non-urgent medical relief, an applicant appealed to the district relieving officer, who could award something temporary to tide the applicant over before he or she went before the poor law guardians to state a case. The application process was designed to be humiliating and was often experienced to be so. In 1885, the Medical Relief Disqualification Removal Act legislated that men receiving medical relief from the Poor Law would no longer lose their vote, which meant the government removed the key obstacle for men to avoid ­applying for medical aid. This act sought to solve a citizenship conundrum: poor law medical relief could restore the able-bodiedness fundamental to masculine citizenship, but receiving that relief had deprived men of their political citizenship. Because the process for obtaining medical relief remained rooted in the poor law application process, however, rather than through consultation with a doctor of choice, many men still hesitated to apply. Indeed, the royal commission investigating the Poor Laws, reporting in 1909, noted that there was no firm evidence to indicate that the 1885 act had increased applications for medical relief.20 Additionally, many people who applied for poor relief

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Health and the English Poor Law  59

on health-related grounds received money or in-kind assistance, as opposed to specifically medical relief, which made the Medical Relief Disqualification Removal Act irrelevant. Studies of the Poor Law have shown that women were disproportionately applicants for and recipients of relief,21 and the Stourbridge Union records confirm this. Of the 4,321 initial applications in my data set for which gender was recorded, 55 per cent were from women. Interestingly, of the 7,331 total applications that note gender, women make up only 52 per cent, which means that although more women than men applied overall, the men who did apply came before officials more often. Some differences across the life cycle also emerge. The overall gender distribution is reversed for applicants in their fifties, at which age men made up 54 per cent of initial applicants. And in the youngest age group, the gap between the genders is the largest, with women constituting almost 60 per cent of applicants under age 25. These numbers imply that young women on their own and men toward the end of their working years were particularly vulnerable. The figures on marital status reveal perhaps the most striking gender differences in the data set (see table 2.1). Of the records noting marital status, 83 per cent of the married applicants were men, and the majority of men who applied were married. By contrast, of the 14 per cent of ­applicants who were single, almost 60 per cent were women, and of the 48 per cent of applicants who were widowed, 82 per cent were women. Under 12 per cent of female applicants were married (compared with two-thirds of the male applicants), and most of these petitioned because of the absence of their husbands. Tellingly, a missing spouse was the reason for only one man’s appeal. These numbers insist on the significance of the intersection of gender and marital status in understanding poverty: men with spouses and women without spouses were most likely to rely on poor law assistance, a prevalence that also illuminates the lifecycle differences noted above. The male breadwinner ideal held up a model of masculinity associated with the independence achieved from gainful employment and the ability to support a wife and children. It is not surprising, then, that the majority of men applying for assistance were married, and many of them asked for relief in the name of their dependants, as was their assumed responsibility. The very fact of an application for assistance, however, demonstrated a man’s failure to provide independently. Married men applied routinely when their wives were about to give birth, for instance, and, as I discuss below, the health of spouses and children dominated

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60  Embodied Citizenship Table 2.1  Applicants for poor law relief, by gender and marital status Married

Single

Widowed Cohabiting All marital statuses

Women No. of female applicants

275

361

1,691

1

2,328

% of female applicants (all marital statuses)

11.81

15.51

72.64

0.04

100.00

% of all applicants (male and female) of this marital status who were women

17.18

59.47

82.13

50.00

No. of male applicants

1326

246

368

1

1,941

% of male applicants (all marital statuses)

68.32

12.67

18.96

0.05

100.00

% of all applicants (male and female) of this marital status who were men

82.82

40.53

17.87

50.00

No. of applicants

1601

607

2,059

2

4,269

% of all applicants

37.50

14.22

48.23

0.05

100.00

Men

Total (men and women)

Note: Statistics are based on information in relieving officers’ application and report books, ­Staffordshire Record Office (S R O ), D585/1/5/27, D585/1/5/29, D585/1/5/32, D585/1/5/35, D585/1/5/47, D585/1/5/50, D585/1/5/68, D585/1/5/70, D585/1/5/73, and D585/1/5/76.

the reasons why they asked for assistance. By contrast, married women’s absence – or underrepresentation – in the applications can also be expected, as their needs were supposedly met through their spouses. When a man could not fulfill his obligation to provide for his dependants, he was the one to petition for their needs. Married women appeared in the records when their circumstances were most equivalent to those of single women and widows: when their husbands were absent or unable to apply themselves. Married female applicants were most often wedded to men who had abandoned their families or were in jail, in the army, or ill in a medical institution, and who could not or would not perform the role of breadwinner. For example, 39-year-old Mary Ann Saunders applied in April 1871 because her husband had “turned her out” of the house.22 Annie Robinson of Cradley, a 29-year-old woman with three dependent children, applied in July 1901 because her husband was in prison for 14 days as a result of

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Health and the English Poor Law  61

gambling debts.23 Like widowed and single women, these women were without husbands to represent them.

G e n d e r , H e a lt h , a n d M a r i ta l S tat u s Health-related issues shaped the reason for appeal in two-thirds of both the initial and the total applications, clearly demonstrating the centrality of health to welfare needs. As historian Lynn Hollen Lees poignantly states, “Even if the rhetoric of pauperism stressed moral decay, its statistics documented physical weakness.”24 This “physical weakness” could encompass acute ailments and injuries as well as more chronic conditions such as fatigue and malnutrition. Although women formed the majority of overall applicants, men submitted 56.5 per cent of applications that contained a reason for appeal based on health.25 Men’s predominance in the health-based applications stems primarily from appeals by married men: almost 80 per cent of married men’s appli­cations were health based, versus just 36 per cent of married women’s (see table 2.2). This discrepancy demonstrates, in an exaggerated form, men’s responsibility for the welfare of their families; they became a­ pplicants themselves when their wives or children suffered from ill health, and the data set implies that the ill health of their families practically defined the reasons men interacted with the relieving officers. This appearance could be deceiving, however. Because ill health was a “respectable” contributor to welfare need, able-bodied male applicants in particular would have been motivated to cloak other causes – such as unemployment – under the cover of health, an issue I explore further below. Gender norms dictated that women were responsible for caring for sick children at home, but 70 per cent of the applicants who applied for relief because of the illness of a child were men, the vast majority of whom were married (see table 2.3). Widowed men made up less than 4  per cent of those applying because of the health of their children, probably because so few widowed men were younger fathers with dependent children. Not one never-married man applied for relief because of sick children. Among women, only six wives applied because of the health of  a child or children, again indicating that husbands / fathers spoke for their dependants. Surprisingly, however, only 25 single women and 26 widows applied for this reason. Almost 1,400 applicants had dependent children, and 54 per cent of these were women, but the health of children simply did not appear regularly in women’s applications, a surprising finding given cultural prescriptions regarding child care.

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62  Embodied Citizenship Table 2.2  Applications for poor law relief for health reasons (with gender and marital status) No. of applications for health reasons

% of gender

% of gender / marital status total applications

% of total

Women Cohabiting Married Single Widowed

1

0.08

100

0.03

99

7.7

36

3.5

336

26

93.1

12

50.6

856

66.3

1,292

100

1

0.07

100

0.03

1,047

69.6

79

37.4

Single

233

15.5

94.7

8.3

Widowed

223

14.8

60.6

8

Men total

1,504

100

Total

2,796

Women total

30.6 46.2

Men Cohabiting Married

53.8 100.0

Note: Statistics are based on information in relieving officers’ application and report books, ­Staffordshire Record Office (S R O ), D585/1/5/27, D585/1/5/29, D585/1/5/32, D585/1/5/35, D585/1/5/47, D585/1/5/50, D585/1/5/68, D585/1/5/70, D585/1/5/73, and D585/1/5/76.

Yet ailing children certainly compounded the difficulties faced by women on their own. This was the case for Hannah Faulkner when her husband, Ezra, died in April 1911. The couple had five dependent children. The 34-year-old Ezra Faulkner had first applied to the Poor Law at the end of March, suffering from phthisis, a disease similar to tuberculosis. The relieving officer awarded cash relief, but Ezra died before he received the money. Hannah began applying on her own two weeks later because of the death of her husband and the illness of her children. She was awarded seven shillings and sixpence per week for 22 weeks and applied every two weeks after that for additional in-kind assistance. At the end of July, the reason for her appeal shifted from the illness of her children to her own ill health, making it even more difficult for her to manage her young family on her own.26 As with applications based on the health of children, applications on behalf of the health of a spouse show a dramatic gender imbalance. In

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Health and the English Poor Law  63 Table 2.3  Applications for poor law relief made on the basis of the health of children Men

Women

Single No. of applications

0

25

% of total applications for this gender

0

43.9

No. of applications

134

5

% of total applications for this gender

96.4

8.8

5

26

3.6

45.6

No. of applications

139

56

% of total applications

71.3

28.7

Married

Widowed No. of applications % of total applications for this gender Total

Note: Statistics are based on information in relieving officers’ application and report books, ­Staffordshire Record Office (S R O ), D585/1/5/27, D585/1/5/29, D585/1/5/32, D585/1/5/35, D585/1/5/47, D585/1/5/50, D585/1/5/68, D585/1/5/70, D585/1/5/73, and D585/1/5/76.

126 cases the applicant’s initial primary reason for asking for relief had to do with an ill, disabled, or injured spouse; all of these applicants were male. An additional 32 men applied because of a wife’s confinement. Including the applicants who applied multiple times, 294 applications were made in the name of the health of a married man’s wife. Thus, even though the records reveal more men than women applying for health reasons, a closer reading clearly demonstrates that it was women’s health needs that brought families and individuals before the poor law authorities. Men, as heads of households, spoke for their wives. By contrast, no woman in my entire sample applied directly because of the ill health of an adult male. This does not imply an absence of women with ailing husbands; in a way, women’s need to care for husbands suffering from ill health is masked in the records, as the men applied for themselves unless they were institutionalized. Because they focus on financial and in-kind provision, the documents subsume the unpaid caretaking responsibility undertaken by women for their husbands. I have argued elsewhere that this masking of women is even clearer in the case of adult children caring for elderly parents, where

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the records almost universally reflect that sons, but not daughters, contributed to their parents’ maintenance.27 Poor Law authorities expected able-bodied men to spend a good deal of time and effort seeking to meet the health needs of their families, perhaps as a way to highlight the significance of a man’s failure as an independent breadwinner. The case of William Swain, a 48-year-old nut seller from Hill, is illustrative: William applied each week in April and May 1871 for assistance because his wife Mary was ill. He applied again at the end of June and in the middle of August for the same reason. The couple had eight children under the age of 16. William’s first six appearances resulted in assistance in kind, but in mid-May, the family was offered the workhouse. It is unclear whether or not they entered, but the following week, they were clearly not in the workhouse as William again received relief in kind. The records do not specify the nature of Mary’s illness, but the fact that William was listed as able-bodied and employed probably contributed to the reluctance of the poor law authorities to grant long-term relief. With eight children and a sick wife, however, William Swain was unlikely to earn enough to support his ­family by hawking nuts.28 Perhaps Mary had been contributing to the household economy and her illness thus created a double burden on the family, depriving them of income as well as requiring additional domestic resources. The 68-year-old Thomas Jones of Stourbridge, a carpenter with three dependent children, also wound up in front of the poor law authorities because of the health of his wife, Mary, who was 20 years his junior. Both Thomas and Mary were listed as not able, and Mary’s illness was specified to be syphilis, while Thomas himself suffered from rheumatic fever. Thomas’s first application, on 31 March 1871, indicates that he sought relief because Mary had suffered a head injury. Because the subsequent applications indicate that she also suffered from syphilis, it raises the question of whether Thomas himself had caused Mary’s injury – or her syphilis. Thomas made weekly applications for in-kind relief on account of his wife’s illness through the beginning of May, and then again throughout June. The relieving officer investigated the circumstances of the Joneses several times, perhaps to ascertain more about the character of a couple in which the wife had venereal disease, but he continued to award them assistance.29 A wife about to give birth also prompted married men’s applications. John Westwood applied in May 1891 for assistance through his wife’s confinement. The couple already had five dependent children. John

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was 41, employed as a loader in a coal pit. While the application does not indicate the nature of his wife’s occupation, it does show that Julia earned four shillings and sixpence a week, a not insignificant sum to contribute to the household.30 The impending birth of their sixth child prevented her from working, depriving the family of her income and probably leading to John’s reliance on poor law relief. Most men applying for assistance for their wives’ confinements received in-kind relief, suggesting that the family needed particular resources such as extra food or blankets to assist with childbirth. Men whose wives were ill, infirm, or injured received medical relief on twothirds of their initial applications, but subsequent assistance for those who continued to need it often came in the form of in-kind relief. A specific petition for medical relief might suggest that the burden of a wife’s illness was not as much financial as physical, and the family turned to the Poor Law as the source of medical care. Yet these applications also show that health issues prevented wives from earning wages, and the loss of their income had an impact on the entire family economy. When the ill health of a wife created financial turmoil for a family it challenged the male breadwinner ideal by forcing the husband to recognize his inability to support the family on his own, which was compounded by his need to look to the state for assistance. While the health of their wives dominated married men’s applications, health was even more prominent in the applications of single men and women: health-based reasons constituted 93 per cent of ­single women’s applications and almost 95 per cent of single men’s (see table 2.2). Single petitioners made up only 14 per cent of all applicants, suggesting an awareness among the poor of the unlikelihood of a single person receiving non-workhouse relief from the authorities. While married women were more likely to be sent to the workhouse than other women (a sign, perhaps, of suspicion surrounding an application distinct from a husband), both single and widowed men were offered the workhouse at rates disproportionate to married men. Poor law authorities, it seems, prioritized outrelief to married men who could claim need in relation to their dependants. Single petitioners, existing outside prescribed gender roles of provider or dependant, had to convince the authorities of their deservedness. Applications based on health – as opposed to unemployment or non-specific destitution – were likely to be given more understanding. Single people with limited or no family resources often sought poor law relief when faced with ill health. Charles Hughes of Hasbury came

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before the poor law authorities in May 1871. A single 49-year-old nailer, he was suffering from phthisis. Hughes asked for medical relief, which was granted, and also received in-kind assistance on his initial application and a week later. On his third appeal, he asked for an increase in relief and was given two shillings a week and in-kind relief over four weeks, suggesting the seriousness of his health condition. The next week, however, he applied again, perhaps too ill to care for himself, and was admitted to the workhouse on 9 June, where he would receive institutional relief and medical care. Two months later and out of the workhouse, he appeared before the poor law authorities and was again granted two shillings a week and in-kind relief for six weeks.31 Sarah Ann Partridge, also an unmarried nailer, at 31 was listed as “not able” because of partial blindness. She had clearly been receiving a pension from the guardians when she first appeared in the records in April 1891 asking for a “renewal,” which she was given: two shillings a week for 27 weeks. Her “debility” made her deserving of this long-term relief. Yet when she applied at the end of August for a medical note for the Birmingham Eye Hospital, she was denied. The application does not indicate the basis for this denial, which was quite unusual. Her relief was stopped altogether at the end of September as she left the district to go hop picking.32 As noted earlier, 26 single women applied because their children – who were entered in the records as “illegitimate” – were ill. All these women had their appeals granted, and all but five received specifically medical relief. All but two had a paid occupation listed – nailers and labourers predominating – suggesting that the women had the double burden of paid employment and child care with few resources. In addition to the 26 unmarried mothers were 20 single women who applied because they were about to give birth; 13 of these were granted the workhouse, which could provide them with rudimentary medical care to see them through their confinements. The numbers regarding widowed applicants are a little more complex because so many of them applied because they were “aged.” In analyzing the applications, in Table 2.2 I have not included “aged” under health-based reasons, unless the application book noted a combination of categories, such as “aged and illness” or “aged and infirm.” Eight hundred and fifty-six widowed women applied with a health-based application out of a total 1691 widowed female applicants. This seems like a very a low number, considering the prevalence of health concerns in the applications overall. Yet, if we include “aged” as a health category for

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the widowed applicants, almost 99 per cent of applications of widowed women and 97 per cent of applications of widowed men aged 60 and over were health related. Indeed, we can probably assume that “aged” in many cases stood in for a variety of health complaints. Health and age thus intersect, and the lack of health becomes implicit for the elderly seeking relief. Age can in some ways also be considered a gender-­ neutral health category, as both men and women were considered deserving of relief because they were aged.

Health and Able-bodiedness Although we cannot equate able-bodiedness with health, since many applicants were both “able” and “ill,” able-bodiedness does present another way of evaluating the physical well-being of those applying for ­assistance. Able-bodiedness was essentially a category of health that represented an applicant’s ability to work. In terms of the Poor Law, it was the most crucial component in evaluating a person’s application. While a particular ailment might keep an applicant from working temporarily, overall assessment of the applicant’s able-bodiedness by the poor law authorities reflected a more long-term ability to work. Men who were unable to work were by definition not healthy. Women’s able-bodiedness mattered only if they had to work to support themselves, as single or widowed women.33 This construction of able-bodiedness tended to erase the financial contributions that married women made to their households, however, and on which their families depended. Able-bodiedness was a specifically gendered category and clearly changed over a person’s life cycle. Among applicants under 40 years old, just over 80 per cent of both men and women were listed as ablebodied. That 20 per cent in this younger age group were “not able” suggests that disability was a primary factor driving younger people to the Poor Law when they could not work to support themselves. In their forties, 80 per cent of women, but only 70 per cent of men, were ablebodied. Men’s disability in the prime of their working lives would have rendered them more deserving of help. Indeed, considering the general socio-medical assumption that women were weaker than men, we might expect to find more women than men labelled “not able.” Yet the expectation that men would be the primary earners brought to the fore their inability to do so in the context of asking for aid. The numbers regarding able-bodiedness change dramatically as the applicants get older. In all age groups 50 years and older, men made up

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the majority of able-bodied applicants, which is what might be expected: in their fifties, 63 per cent of men but only 48 per cent of women were able-bodied; in their sixties the figures drop to 18 and 4 per cent, respectively; among those seventy and over, 1 per cent of men were able and less than 0.5 per cent of women. Of the applicants who applied because they were “aged” or for some combination of age and ill health, almost all were listed as not able-bodied. This again supports the idea that although age was not explicitly a health-based reason for appeal, in many cases “aged” did indeed imply health problems. The vast majority of married men who applied for assistance solely for reasons relating to the health of their wives or children were classified as able-bodied, suggesting that the health of dependants provided a mitigating circumstance for able-bodied men to be considered deserving of relief outside the workhouse (outdoor relief). 93 per cent of married men applying for aid to support an ailing spouse and 99 per cent of married men applying for their sick or injured children were ablebodied. Yet these able-bodied men needed the help of the state to provide for their families, and this was particularly the case when an illness or injury complicated the functioning of the household. When a wife was unable to tend to her domestic responsibilities because of ill health, in-kind relief could tide over a family used to having the woman taking care of the provision of food. Similarly, any wages a wife might earn would presumably be lost during her illness. Although two-thirds of applications contained health-related reasons for appeal, only 22 per cent of applicants received explicitly medical relief, in the form a note to see a doctor, admission to an infirmary or the workhouse sick ward or an asylum, some kind of medical “equipment” such as a truss, or unspecified “medical relief.” These are the ­recipients who would have benefited from the Medical Relief Disqualification Removal Act. The vast majority who applied for health-based reasons or who were “not able” received cash or in-kind relief. Women received almost two-thirds of the cash grants, whereas men received about two-thirds of the medical assistance. This is a consequence not only of the greater number of applications for health reasons on the part of men but also of the tendency of the authorities to be more ­lenient with cash grants for women as they were reluctant to give cash to able-bodied men. Cash grants to men went overwhelmingly to ­married men, whose need was defined in terms of their dependants. Widows, by contrast, received over 80 per cent of the cash grants given to women.

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Conclusion The applications for relief from the Stourbridge Poor Law Union demonstrate that the poor sought aid for various reasons, some of them clearly related to their positions as men and women, providers and dependants, husbands and wives. Low wages, lack of employment opportunities, and the expectation that men would support them created particular vulnerabilities for women on their own. Married men, unable to maintain their wives and children without assistance, sought poor law relief to bolster their ability to provide. Gender and marital status very clearly shaped individuals’ access to poor law relief, which in many ways was structured to give priority to men’s applications. It is clear that the majority of women and men applying for poor law relief did so because of genuine health problems. Yet because the poor law system categorized ill health – but not various other factors – as a respectable source of need, applicants would also have been tempted to present their cases through the lens of the body, in terms of health, able-bodiedness, or the lack thereof. Relieving officers and guardians almost universally granted relief to such applications. The rudimentary welfare system of the Poor Law privileged relief to those who applied for health-based reasons: if assistance could restore an applicant’s health, then it was hoped the petitioner would no longer burden the state. Health, from the perspective of the poor law authorities, was above all the ability to perform expected roles: for men, this meant earning money and supporting families; for women, it meant performing the tasks of social reproduction and providing supplemental income when needed. From the perspective of the applicants, health signified the ability to maintain independence, and for men, full citizenship, by staying free from state assistance. Petitioners needed to speak the language of the poor law authorities to be considered deserving, and health provided a means to do so. A health-based appeal seems to have been particularly significant for able-bodied married men, whose ability to work but inability to provide sufficiently for their families challenged the male breadwinner ideal. A wife or child’s illness could enhance a claim for assistance while simultaneously foregrounding the necessary contributions to the household by multiple members of the family. In particular, if a wife’s illness prevented her from earning wages it could render a household unable to survive without help. This could focus attention on a husband’s failure to uphold the male breadwinner norm. Similarly,

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the poor law applications highlight the ways in which ill health contributed to men’s inability to bring sufficient wages into the household. For the elderly, ill health was assumed, and the Poor Law considered them deserving of help. In many ways, to be “aged” for a man meant to be unable to perform the breadwinner role. Once that expectation was gone, a man could be deserving. For older women the dependence that was considered natural to all women was simply increased. The institution of national health insurance in 1911 created the opportunity to rethink the assumptions about gender, health, and work that operated in the poor law applications. Yet as Helen Jones has argued so clearly in her study of health and the state in the twentieth century, the new health insurance scheme continued to filter assistance through the male head of household and to value men’s health over women’s. While the Poor Law was reluctant to give cash to able-bodied men, cash benefits, not medical ones, were the key to the [new] system because it was assumed that if the man, who brought in the family wage, could continue to have an income when off work through illness, he could maintain himself and his family. A range of evidence strongly pointed to women suffering worse health than men, but this was irrelevant as women were not perceived to be chief breadwinners. The fact that in many families the man did not provide a family wage was not taken on board, except insofar as single women were to be covered. Voluntary insurance for married women was really a footnote to the scheme.34 While 1911 is rightly regarded as a watershed in terms of state support of health care, we should also recognize the cultural continuities that shaped the new health insurance system. The national state valued the health of men and women differently, as did the locally administered Poor Law. Because men’s ability to provide was prioritized over women’s assumed roles in the domestic sphere, the state, in both its local and central manifestations, prioritized restoring men’s health even though the absence of health for women had significant repercussions for individuals and families alike. Additionally, those who were not covered under the new national health insurance continued to rely on the Poor Law for health care. Gendered ideas about social roles infused two disparate but parallel welfare systems, both of which imagined lack of health to be more of an

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issue for men than women, and which filtered women’s health care to a large degree through the men to whom they were married. Neither system recognized the key financial contributions women brought to their households. When those contributions were threatened by poor health, their absence caused men to seek assistance not in their own names but in those of their wives.

Acknowledgments This essay could not have been completed without the outstanding ­research assistance of Christopher Hubble. I thank Myra Rich and the editors and participants in the Gender and Health Histories Symposium for their time and care in offering suggestions. The research for this  chapter was supported by faculty development grants from the University of Colorado Denver and the Walter S. Rosenberry III Charitable Trust Research Fund of the University of Colorado Denver Department of History.

notes   1  Staffordshire Record Office (S R O ), D585/1/5/29, Application and Report Book (ARB), Cradley, 1891. In cases where both husband and wife are named, I will refer to them by their first names.  2 S R O , D585/1/5/32, A R B , Cradley, 1901.  3 S R O , D585/1/5/76, A R B , Brierley Hill, 1911.   4  Rose and Novas, “Biological Citizenship,” 440.   5  On the male breadwinner ideal broadly see Horrell and Humphries, “The Origins and Expansion of the Male Breadwinner Family”; Janssens, “The Rise and Decline of the Male Breadwinner Family”; Seccombe, “Patriarchy Stabilized.” For discussions of the breadwinner ideal in its relationship to welfare in Britain, see, among others, Clark, “The New Poor Law and the Breadwinner Wage”; Levine-Clark, “Engendering Relief”; Pedersen, Family, Dependence, and the Origins of the British Welfare State.   6  Sidney Webb and Beatrice Webb, The State and the Doctor (London: Longmans, Green, 1910), 1–2.   7  See, for example, Hodgkinson, The Origins of the National Health Service; Flinn, “Medical Services under the New Poor Law”; Crowther, “Paupers or Patients”; Hurren, “Poor Law versus Public Health.”   8  On gender and the Poor Law, see Thane, “Women and the Poor Law in Victorian and Edwardian England”; Lees, The Solidarities of Strangers,

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especially “Gender, Family and Work,” 135–45, and “Women and Welfare,” 196–210; Clark, “The New Poor Law and the Breadwinner Wage”; Long, Conversations in Cold Rooms, especially “Regulating Poverty, Regulating Gender”; Levine-Clark, “Engendering Relief.”   9  For example, see Gordon, Women, the State, and Welfare; Orloff, “Gender in the Welfare State”; Lewis, “Gender and the Development of Welfare Regimes”; Daly, The Gender Division of Welfare. 10  The archival collection on which this analysis is based is composed of the application and report books for Stourbridge Union, held at the Staffordshire Record Office (S R O ). From the Halesowen District, D585/1/5/27, D585/1/5/29, D585/1/5/32, and D585/1/5/35. From the Stourbridge District, D585/1/5/47, and D585/1/5/50. From the Kingswinford District, D585/1/5/68, D585/1/5/70, D585/1/5/73, and D585/1/5/76. The records, for the most part, exist in ten-year intervals; I assume that archivists at some point made the decision to keep the materials relevant to census years. 11  For general histories of the Black Country in this period, see Allen, The Industrial Development of Birmingham and the Black Country; Barnsby, Social Conditions in the Black Country; Trainor, Black Country Elites. Carol Morgan has taken the Black Country example to study women’s work and gender in Women Workers and Gender Identities. 12  “Adult” for the Poor Law meant age sixteen and above. For this analysis, I am only examining records of adults. 13  The New Poor Law has occupied historians for many years. For an introduction to this extensive literature, see Lees, Solidarities; Brundage, The English Poor Laws. 14  On the regional variations in the implementation of poor law policy, see Hollen Lees, Solidarities; Brundage, The English Poor Laws; Digby, The Poor Law in Nineteenth-Century England and Wales; Fraser, The New Poor Law in the Nineteenth Century; Wood, Poverty and the Workhouse; Driver, Power and Pauperism. 15  See Lees, Solidarities; Brundage, The English Poor Laws. 16  For discussions about gender and work in the later nineteenth century, see among others, John, Unequal Opportunities; Rose, Limited Livelihoods; Lown, Women and Industrialization. 17  Parliamentary Papers, Report of the Royal Commission on the Poor Laws and Relief of Distress, XXXVII, Cd.4499 (London: H M S O , 1909), 211. 18  Royal Commission on Poor Laws, 211. 19  Levine-Clark, “Engendering Relief.” 20  Royal Commission on Poor Laws, 254.

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21  For example, see Lees, Solidarities; Thane, “Women and the Poor Law.” 22  S R O , D585/1/5/26, A R B , Halesowen, 1871. 23  S R O , D585/1/5/32, A R B , Cradley, 1901. 24 Lees, Solidarities, 191. 25  If we add the category “aged” to the health categories, the percentage of male applicants drops to 51 per cent, still a majority. I will discuss below the complications regarding the category “aged.” 26  S R O , D585/1/5/35, A R B , Hill, 1911. 27  For further discussion of these issues, see Levine-Clark, “The Gendered Economy of Family Liability.” 28  S R O , D585/1/5/27, A R B , Hill, 1871. 29  S R O , D585/1/5/47, A R B , Stourbridge, 1871. 30  S R O , D585/1/5/50, A R B , Stourbridge, 1891. 31  S R O , D585/1/5/27, A R B , Hasbury, 1871. 32  S R O , D585/1/5/29, A R B , Halesowen, 1891. 33  On gender and able-bodiedness, see Levine-Clark, “Engendering Relief.” 34  Jones, “Health,” 163.

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3 Constructing Hygienic Subjects: The Regulation and Reformation of Aboriginal Bodies Meg Parsons The state, in the name of public health, is empowered to test, handle, move, and segregate people, especially those deemed physically or ­emotionally needy. In the twentieth century, as Alison Bashford has demonstrated, an emphasis on domestic and personal hygiene saw the formation of hygienic boundaries of rule, whereby populations were categorized and separated into those capable of self-care and those marked incapable.1 In the state of Queensland, the convergence of popular and medical representations of Aboriginal people as incapable of performing the modern rituals of health and hygiene reinforced and justified the government’s decision to place the Aboriginal population outside of the social body and inside reserves and dormitories for much of the twentieth century. Within the reserves, women and men were subject to differential treatment. In Queensland, a colony founded on the exploitation of indentured non-white labour, the management of health involved the erection of boundaries and enclosures to police bodies, microbes, and race relations. This essay explores twentieth-century Queensland through the lens of western medicine and its interactions with the state’s indigenous Aboriginal population. I am primarily concerned with the introduction and significance of western medicine and what role biomedical knowledge played in the construction of Aboriginal bodies. In particular I explore how government officials used the discourse and practices of hygiene as a means to transform populations into suitable, although not necessarily equal, or healthy, members of civil society.

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In 1901 the federation of the six Australian colonies marked the beginning of the new nation based on the presumption of the settlement of the entire continent by a healthy hard-working white race. For newly emergent Australian nationalists, the “menace of colour” was alarming.2 Queensland was a key battleground for debates about the status of White Australia owing to its tropical climate, its long-standing usage of non-white labour, and its close proximity to Asia.3 From its inception, Queensland was economically dependent on “black labour” to a far greater degree than the other Australian colonies.4 Indeed, labour ­arrangements in colonial Queensland in many ways paralleled those of Pacific Island colonies, most notably the use of indentured Pacific Islander “kanaka” labourers.5 In the twentieth century Aboriginal and Torres Strait Islander labour replaced the labour of indentured Pacific Islanders, who had been the mainstay of North Queensland’s fisheries and sugar industries until Australia’s federation in 1901. White women and men supposedly endangered their health and reproductive capacities simply by being in Queensland’s tropical conditions, and thus physical labour was seen as the exclusive domain of Aboriginal and Torres Strait Islander workers. Aboriginal women were contracted out as domestic servants to white households. Aboriginal men were employed in the primary industries: on pastoral stations, horticultural operations, and fishing boats. In addition to the rural sector, the other main employer of Aboriginal men was the police force, which employed them as trackers.6 Government-run reserves and church-run missions, such as the Cherbourg settlement discussed in this essay, were key sites at which to transform the Aboriginal population into useful, individualized economic units for the Queensland state. In what follows I draw on examples from Cherbourg Aboriginal settlement, a government-run Aboriginal reserve in the South Burnett district, southern Queensland. Initially established as a private enterprise by a Salvation Army missionary, William J. Thompson, in February 1901 and named Barambah mission, the institution was taken over by the government in 1905 and quickly grew as Aboriginal people from across the state were removed to the reserve. Over the course of a thirty-year period, Cherbourg settlement emerged as the largest government-run Aboriginal reserve in Queensland. By the 1930s, it was home to more than 900 Aboriginal people and boasted a school, dormitories, office, store, sawmill, jails, sport fields, cottages and camps, staff residences, a cemetery, and the state’s largest Aboriginal hospital.

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The state government of Queensland sought to define and regulate Aboriginal people and their health during the 1920s and 1930s through the introduction of medical inspections for Aboriginal workers. The state’s narratives of gender and health crossed over with those of race and labour and, I argue, created persistent concerns about the status of Aboriginal bodies: Were they healthy? Were they clean? Were they pregnant? Were they of mixed race? Such questions raised both on and off the reserve saw the development of a range of regulatory practices that sought to examine, discipline, and ultimately reform Aboriginal bodies into hygienic workers. The Australian state’s notion of hygiene in the interwar years was very different to the post-war concerns of individual American men about hygiene that Thomas Wendleboe discusses in this volume. In the hands of the Queensland state, hygiene entailed coercive practices aimed to remould Aboriginal culture. I begin by providing a brief outline of the historiography of colonial medicine and indigenous peoples before discussing the state of Queensland’s Aboriginal policies, most notably the creation of the Aboriginal reserve system. This is followed by an examination of legislative reforms adopted in the 1930s in response to the perceived threat of “miscegenation.” I then discuss the introduction of medical inspections on Cherbourg settlement and how the emphasis on ­hygiene practices within the dormitories, cottages, and school was primarily directed at the production of suitable Aboriginal male and female workers rather than improving Aboriginal health outcomes.

Colonial Medicine, Public Health, and Indigneous Peoples The intersecting histories of public health and colonial governance have become an important area of scholarly study over the last two decades. At the risk of generalizing the ever-more varied literature on colonial medicine, the essential proposition of this scholarship is that biomedicine was a constitutive part of colonial power.7 Biomedicine served to legitimize colonial rule and was a means to regulate, normalize, and discipline indigenous peoples as embodied subjects. Medical discourses are at the centre of what Ann Laura Stoler and Frederick Cooper have termed the “tensions of empire.” The tensions refer to the “particular universalising claims of European ideology and the particularistic nature of conquest and rule, the limitations posed on rulers by the reproduction of difference as much as the heightened degree of exploitation and dominations that colonization entailed.”8

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Numerous scholars have explored the question of how western medicine related to colonial power over colonized peoples, economies, and bodies. David Arnold, in his influential study of colonial medicine in nineteenth-century India, argues that the introduction and circulation of biomedical knowledge and practices played a fundamental part in the regulation of colonial subjects by the enlarging state.9 Megan Vaughan, in her work on colonial Malawi, demonstrates the inherent limitations of viewing colonial medicine in monolithic terms. Vaughan suggests that while colonial medical discourse constructed “the African” as diseased, dirty, and sexually perverse, in practice colonial officers were rarely willing to follow through on the implications of this construction.10 Moving away from discourses and texts to the actual morbidity, mortality, and medical treatments, Mary-Ellen Kelm reminds us of the physical dimensions of colonial medicine in her study of Aboriginal health in British Columbia from 1900 to 1940. Kelm demonstrates how the deterioration of Canadian Aboriginal health following contact with non-Aboriginal peoples was the result not simply of faceless pathogens but also of government policy-makers and department officials who consistently sacrificed Canadian Aboriginal bodies for the purposes of national development and financial cost-saving.11 Similarly, in twentieth-century Queensland, as I outline later, government officials frequently emphasized maximizing Aboriginal labour while minimizing expenditure on Aboriginal housing, nutrition, and health care. Recently, historians of medicine have turned their attention to the topic of public health to explore the complex relationships that arose between colonizer and colonized, dominant and disposed, healer and patient, and above all, the state and the individual.12 Along with Kelm’s work, two Australian studies (Alison Bashford’s Imperial Hygiene and Warwick Anderson’s The Cultivation of Whiteness) provide the genesis for this chapter.13 Bashford’s examination of the discourse of hygiene in Australia from the 1860s to the 1940s highlights how public health was one method through which the emergent Australian nation came to be managed and governed. Anderson charts the rise of bacteriological medicine in Australia and documents how doctors and scientists began to refer to non-whites as tropical disease carriers to be identified and cleansed within the laboratory and nation-state. Read together, the studies of Bashford and Anderson offer different but complementary understandings of biomedical knowledge and practices in early ­twentieth-century Australia. Moreover their work raises questions about health, hygiene, governance, and the extent to which

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race and ethnicity served as constants in the framing of disease and the provision of health care, yet neither specifically examines Aboriginal health and well-being. This chapter, therefore, seeks to examine the extent to which the Queensland state assumed responsibility for Aboriginal health through the case study of Cherbourg Aboriginal settlement. Through this case study I examine how government policies, although not specifically medical, nonetheless shaped the ways in which the authorities categorized, situated, and managed Aboriginal people through discourses of hygiene and labour.

Queensland Aboriginal Policies: S e g r e g at i o n a n d L a b o u r Driven by a mixture of economic, eugenicist, and humanitarian ­imperatives, government-run reserves and church-run missions pro­ liferated across the state of Queensland following the passage of the Aboriginals Protection and Restriction of the Sale of Opium Act of 1897. The act and its subsequent amendments empowered government “protectors” – police officers, civil servants, magistrates, and missionaries – to forcibly remove Aboriginal people to reserves, to separate children from their families, to control Aboriginal employment and income, to prohibit Aboriginal languages and customs, and to regulate Aboriginal movement. Removal orders, issued by the Chief Protector of Aboriginals, became a key mechanism by which the Queensland government attempted to control Aboriginal lives and to regulate Aboriginal behaviour. The orders authorized the police to forcibly remove Aboriginal people (and, from 1904, Torres Strait Islanders) to institutions. While similar policies authorizing the removal of Aboriginal people to institutions were introduced to the other Australian states and territories in the twentieth ­century, these powers were used more rigorously in Queensland than elsewhere.14 By the 1930s, roughly half of Queensland’s Aboriginal population was housed in government-run reserves or church-run missions, a far higher rate of institutionalization than in other states and territories.15 The Queensland government was unique in that it favoured a policy whereby whole families (or at least mothers and their dependent children) were taken to Aboriginal reserves; in contrast, the ­removal policies of the Northern Territory and Western Australian governments favoured the removal of unaccompanied children.16 ­ Similarly, Queensland, alone of Australia’s states and territories, did

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not accede to the ideology of biological absorption (the loss of Aboriginal physical characteristics through interracial relations).17 Instead, Queensland officials, as in many American states, sought to prevent interracial relations and emphasized the importance of racial purity (of white and Aboriginal alike). The reserve system was heavily subsidized by deductions from Ab­ original workers’ wages and the labour of Aboriginal inmates and white ­missionaries.18 Herein rests the dual contradiction embedded in Queensland as a colonial space: the persistent tension between white demands for cheap Aboriginal labour and white dislike of close proximity to Aboriginal people; and the tension between this dislike and the growing imperative to provide medical and educational services for ­Aboriginal people. These tensions were evident in the operations of Cherbourg Aboriginal settlement. Thompson originally intended the mission to be a place where local Aboriginal people would voluntarily come to live and could be protected from “European civilisation and vice” and educated in Christian values. However, following the government’s takeover of the institution in 1905, government administrators approached the task of managing Cherbourg in a decidedly utilitarian manner; they were asked to save pounds, not lives or souls.19 Despite opposition from the local white population, who labelled Aborigines “emaciated wretches or rather masses of human corruption,” Cherbourg became southern Queensland’s Aboriginal labour depot.20 White demand for cheap Aboriginal labour ensured that complete racial segregation was never a financially attractive option for the government, and thus generations of young Cherbourg men and women were sent off the settlement from the age of 12 years to work as labourers and domestic servants, sometimes returning for brief periods at the end of their twelve-month contracts.The system of institutionalization and unfree labour that developed in Queensland meant that Aboriginal people were already subject to a high degree of surveillance, both of their bodies and of their movements.

M i s c e g e n at i o n a n d t h e R e f r a m i n g of Aboriginal Health In 1932 Dr Raphael Cilento undertook a medical survey of North Queensland’s Aboriginal communities on behalf of the Commonwealth Health Department. In his report, Cilento called for the fundamental reorganization of Queensland’s long-standing Aboriginal reserve system

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along the lines of racial hygiene: “The care of the natives is essentially a matter of constant medical supervision – a supervision that goes all the way from actual disease control to the control of adequate food supplies and suitable working conditions, and the methods of recreation and educational improvement.”21 Cilento’s interest in Aboriginal health was explicitly related to his racial ideology. To him, the regulation of health and the regulation of race were one and the same thing, with racial purity an essential part of his overall understanding of health. Hence the spatial isolation of all Aboriginal people was deemed a moral and medical necessity designed to prevent interracial relationships and ensure the purity of both the white and Aboriginal races. Cilento perceived poor health among Queensland’s Aboriginal population as “a shame” and a reflection of the failure of colonial (white) medicine to protect “primitive” peoples who were too “significantly low in the scale” to have “consciousness and independence of thought and action.”22 Under Cilento’s direction Queensland’s Aboriginal population, men and women, boys and girls, were reframed as a “health problem” to be solved by the state. The work of Cilento seemed to confirm Chief Protector J.W. ­Bleakley’s long-standing fears about racial contamination, and Bleakley sought to solidify the state’s racial policing system through legislative reform. The Aboriginals Protection and Restriction of the Sale Opium Act Amendment of 1934 extended departmental controls to include ­marriage arrangements, living conditions, and health status of Aboriginal people, and “cross-breeds” (people of Aboriginal and non-white non-Aboriginal parentage) were also brought under the control of the state. The 1934 Amendment Act was designed, Bleakley stated, “to prevent undesirable marriages from being performed by irresponsible persons.”23 Marriages between white and Aboriginal persons became “absolutely prohibited,” and Aboriginal women were given “every encouragement … to marry amongst their own race.” Indeed, Aboriginal marriages now required government approval. Bleakley reported that the policy “naturally resulted in the mating of half-castes, removed to the reserves, with other half-castes or aboriginals and the birth of half-caste children,” a result substantially “less evil than the promiscuous intercourse of … crossbreeds with the lower elements of the white population.”24 It is difficult to determine how many marriage applications were rejected because of a lack of government reporting of such applications. The 1934 amendment act regulating Aboriginal marriages also included provisions to monitor the “health and social conditions” of

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Aboriginal people.25 Section 10 dealt specifically with Aboriginal health. Under the legislation, all Aboriginal or “half-caste” people were required to submit to medical examination if a white official suspected them of suffering from an infectious disease. Any attempt by Aboriginal individuals or groups to avoid, resist, or refuse examinations became a punishable offence.26

Medical Surveillance and the Cherbourg Aboriginal Settlement The medical surveillance that was introduced in Cherbourg reserve following the 1934 amendment act was as much about fear of racial contamination as it was about health. Medical inspections differentiated between Aboriginal male and female bodies and were designed to reduce white concerns about Aboriginal workers as potential sexual, racial, and infectious contaminants of white homes, bodies, and the wider body politic. The 1934 legislation, and its successor, the Aboriginals Preservation and Protection Act of 1939, sought to survey the bodies of Aboriginal people as workers (or, in the case of children, workers in training) through both medical inspections and informal daily hygiene inspections, within the institutional setting of the Aboriginal reserve. From the mid-1930s compulsory medical examinations became a feature of life for Cherbourg inmates. Officials were empowered to conduct both medical and hygiene inspections of persons and places under both state legislation and internal department regulations. Hospital staff were required to inspect all new arrivals for signs of infectious disease. The introduction of medical inspections was consistent with Cilento’s earlier recommendation that all Aboriginal people in the state be examined and, if necessary, sent to one of Queensland’s offshore islands (Peel and Fantome islands) used for medical supervision and treatment.27 Deputy Chief Protector O’Leary stated, “As the first step in this direction [it] has been decided that all natives under order for removal to any Mission or Settlement other than Palm Islands, should be subjected to a medical examination at the most convenient point prior to their admission to the particular reserve.”28 The ability of Aboriginal people to enter and leave reserves hinged on physical fitness. Employment both on and off the reserve was dependent on a medical inspection and a certificate issued by the reserve’s visiting medical officer attesting that the person was disease free. In this way Aboriginal labour and health were inextricability linked. Ruth

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Hegarty recalls, “Every time, before we went out to work, we had to see the doctor before a check-up. No girl was allowed to work unless she had a clean bill of health. They were very strict about this.”29 Medical surveillance provided a way for the Queensland Chief Protector’s Office to reassure the white public, and white employers in particular, that Aboriginal people were clean, healthy, and reliable workers. In 1933, the year before the amendment act was introduced, the diagnosis of two cases of leprosy at Cherbourg reserve caused widespread panic among local white residents. The South Burnett Times declared the Cherbourg reserve “a menace to public health of the district,” and the councils of the neighbouring white townships of Murgon and Wondai demanded the removal of the reserve to a “location where climatic and other conditions are far more congenial to its inmates, and away from proximity of the popular townships and what such proximity entails.”30 Home Secretary E.M. Hanlon dismissed such suggestions and declared that all Aborigines at Cherbourg were “under strict medical supervision. They were kept under observation and on the slightest sign of contagious or infectious disease they were isolated or removed” to an  offshore ­island  institution.31 Similar incidents regularly occurred throughout Queensland, as white concerns about Aboriginal disease prompted the government to establish Aboriginal-only isolation facilities on Fantome Island, first for venereal diseases in 1928, and later for leprosy in 1940.32 Medical surveillance of Aboriginal bodies was designed to reduce the likelihood of the white public seeing signs of Aboriginal ill health. When medical surveillance failed and Aboriginal workers were found by their white employers to be “diseased,” government officials took considerable measures to reassure and in some cases compensate white employers for their loss of labour.33 For instance, when a young Aboriginal woman who had been housed at the Cherbourg girls’ dormitory was diagnosed with leprosy in 1945, Ruth Hegarty and other former dormitory girls were recalled to Cherbourg to be examined by hospital staff. The Chief Protector’s Office, by then renamed the Department of Aboriginal and Torres Strait Islander Affairs, “wanted to redeem itself,” Hegarty argued. “It didn’t want employers thinking it made mistakes and sent out girls who were unhealthy.”34 In a sense the medical policing introduced on Cherbourg and other settlements under the direction of Cilento and Bleakley brought Queensland into realignment with the colonial medical practices of New Guinea and Southeast Asia. As Alex Cameron-Smith demonstrates, Cilento’s experiences as a colonial medical officer in Malaya and the

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Australian colony of New Guinea undoubtedly influenced his attitudes toward Aboriginal health in the Queensland context. In 1926, at the International Pacific Health Conference, Cilento observed how colonial health programs in the Pacific Islands and Southeast Asia helped to increase the number of indigenous workers. In advising that Queensland adopt a system of index cards to classify and code inmates like those used in New Guinea, Cilento suggested the “whole aboriginal problem” be regarded as an “indenture system.”35 The production of a healthy Aboriginal population would provide Queensland (and the Australian nation as a whole) with an expanded pool of labourers – hygienic nonwhite subjects – vital to the continued expansion of tropical Australia. The creation of well-run reserves, Cilento declared, promised a future whereby the Aboriginal race would be an “economic asset to Australia.”36 Bleakley similarly wanted to transform Aboriginal people into “useful economic and social units.”37 Yet unlike Cilento and Bleakley’s counterparts in other parts of the country, A.O. Neville (Western Australia) and Cecil Cook (Northern Territory), all of whom portrayed their policies as secular and scientific, the chief protector himself emphasized the ways in which his Christian ideals informed his work. Bleakley considered the protection of Aboriginal people, a “child race,” from “unscrupulous whites” as his moral and Christian duty.38 In his view Aboriginal people first required an education in hygiene, economic responsibility (for men), and domesticity (for women), and only after they had learned these principles of civilization would they “be fit material for making a good Christian.”39 Civilization and medicalization were, in his view, the first step toward religious conversion.

Sex, Health, and Race: Inspecting Aboriginal Male and Female Bodies Government Aboriginal policies were typically framed to apply to both sexes. As Heather Goodall argues, however, the implementation of such policies always occurred within a landscape of “existing genderdifferentiated conditions” and therefore typically had a heavier impact on either men or women depending on the circumstances.40 On the Cherbourg settlement, medical inspections of Aboriginal men were undertaken in public settings but those of Aboriginal women in private. Albert Holt, a former Cherbourg resident, recalls being subjected to a compulsory medical inspection at the age of fourteen:

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The night before my induction into the workforce my brothers … told me to scrub up. I was bewildered trying to guess why. The next day I found out. All the males on the mission [Cherbourg] were made to go to the old hall at eight in the morning, and I got the shock of my life. There was a hygiene officer from the Native Affairs Health Department. We all had to parade before him and drop our trousers so that he could inspect our boonthies ­[backsides], and those with foreskins had to expose their budoos [penises]. He would make comments about built-up cheese, suggesting we have our penises cleaned. This was given a double B rating … We were not only disgusted and humiliated, but also outraged. I cannot forget the absolute disgust the males of Cherbourg felt at being subjected to this degrading experience. I remember the elders looking for options to not be involved in such a public examination.41 Throughout the first half of the twentieth century, white doctors routinely performed medical inspections of Aboriginal people (both male and female) in public forums. In a 1926 visit to Palm Island reserve, for instance, Dr Cecil Cook instructed all inmates to be “completely stripped of clothing,” line up single file, and await his examination for signs of leprosy.42 Yet on the Cherbourg settlement, Aboriginal women submitted to medical examinations conducted by a doctor and nurses in the more private setting of a hospital. This division of medical examinations between public and private spaces reflected white views of Aboriginal male and female bodies. Colonial accounts of Australian Aboriginal men, Julia Martinez and Claire Lowrie demonstrate, expressed a very different gender binary from those in other colonial contexts. Whereas in the United States, there was an “imagined simmering sexuality of the black man,” in Australia there was an “an attempt to completely diffuse the sexuality of Aboriginal men and render him sexually, as well as socially, impotent.”43 Although depictions of Aboriginal men as hunters might imply a “warlike” character, this hunter trope was not linked with sexuality or virility. Fiona Paisley points out that popular depictions instead emphasized that “self-control was inherent to Aboriginal masculinity and that sexual aggression was absent from the Aboriginal man’s make-up.”44 Aboriginal men were positioned as objects of pity, “struggling to survive in the modern world” and to transform themselves from “capricious hunter into the steady labourer.”45

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The medical inspection of Aboriginal men, including elders, in a public forum infantilized Aboriginal men as if they were children in need of basic hygiene inspections from white men. It also sought to emasculate them or render them impotent. In 1938, the Department of Health and Home Affairs publication, then under Cilento’s control, reported that Aboriginal males could gain “back some modicum of [their] racial pride” only through white male supervision and instruction. If “he is shown how to earn a living, how to adapt himself to village life, how to recover some racial pride and independence,” official propaganda proclaimed, “he will realize the best in his nature.”46 Labour and life within the nuclear family, however, were not enough. Bleakley argued that only once the Aboriginal male understood and accepted “his responsibility for the support and protection of those dependent upon him, maintaining the sanctity of home, and the chastity of his women” would he be capable of self-governance.47 The attainment of male subjecthood, wherein Aboriginal men would be subjects of the state as opposed to citizens, therefore depended as much on Aboriginal men’s control of Aboriginal female sexuality as it did on their own behaviour. The rising number of “half-caste” children born to Aboriginal mothers in the interwar period was seemingly evidence not only of Aboriginal male impotence but also of Aboriginal female immorality. Accordingly white men (and white women) were responsible for the regulation and reformation of Aboriginal women. Officials classified Aboriginal women as oversexed and uncontrolled. In 1934, Queensland’s Governor Leslie Wilson, for instance, labelled Cherbourg’s female inmates inherently “immoral” and suggested that all cases of miscegenation occurred because “the native girls, who, by temperament and a desire to have a child by a white father, encourage white men in … every way.”48 He argued that the only solution was “constant roll calls and adequate guards” to “prevent any females from going outside.”49 Simultaneously the most needy and most unruly members of the Aboriginal population, women as a group were deemed to require special government supervision. Orders issued by the chief protector frequently listed immorality as the justification for removing Aboriginal women (and their children) to the Cherbourg settlement; those for Aboriginal men typically listed unemployment and ill discipline.50 Such removal orders declared Aboriginal females to be “immoral,” “uncontrollable,” “insubordinate,” and therefore in need of “care and protection” for both themselves and their children.51 Given this construct of Aboriginal femininity, it is unsurprising that Aboriginal women and

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girls were inspected in the clinical setting of Cherbourg hospital by white doctors and nurses rather than in public.52 Classification as both malleable and needy, Warwick Anderson argues, made Aboriginal women prime candidates for the government’s program of “medicalization and civilization” to a far greater extent than Aboriginal men.53

Dormitory Living Although official policy dictated that Aboriginal men were the key to racial improvement, in practice white officials put greater emphasis on regulating Aboriginal women and girls. Bleakley went so far as to note in one annual report that the “rescue and care of young women and children” was “the most important” aspect of his work.54 A decade ­earlier, in 1925, Bleakley had officially opened the Stopford Home for Aboriginal Girls on Cherbourg for the purpose of ensuring the “strict segregation of … unmarried females.”55 The girls’ dormitory formed the centrepiece of his plans to reform and remake Aboriginal females into suitable wives, mothers, and domestic servants through training and the regulation of marriages. The girls’ dormitory was the largest and most prominent building on the settlement, a testament to the  Queensland government’s commitment to control and reform Aboriginal women. The new girls’ dormitory, six times larger than the previous dorm, was two storied and flanked by verandahs, complete with rooms for dining, sewing, dressing, staff quarters, storage, and sleeping. The upper floor was divided into two main sections, one of which housed the younger girls and the other the older girls. At either end of the girls’ rooms were the sleeping quarters of native staff members (older Aboriginal women responsible for monitoring girls’ behaviour). A new dormitory was also constructed for Aboriginal women and infants in 1927 (known as the “babies’ dorm” or “mothers’ quarters”), and one for Aboriginal boys in 1928.56 The construction of three new dormitory buildings allowed the administration to increase the number of inmates. In 1910, only three per cent of Cherbourg’s population lived in dormitories; the vast majority of Aboriginal inmates lived in camps, spread throughout the reserve and organized along language and kinship ties. By the 1930s, however, these numbers had changed markedly. Approximately one-quarter of the population lived in newly built weatherboard cottages (known as the “village”), another quarter lived in the dormitories, and the remainder lived in camps. Inmates were housed in four separate dormitories:

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the girls’ and boys’ dormitories, the Aboriginal women and infants’ dormitory, and the single men’s quarters.57 Furthermore, by the 1930s, sixty-six per cent of Cherbourg’s children aged between five and fourteen were housed in the dormitories, at a ratio of approximately two girls to every boy.58 Sexual difference was at the heart of segregation, with the aim of creating different futures for young Aboriginal women and men.59 From the age of four or five, children were separated from their mothers, divided by sex, and placed into the respective dormitories. Ruth Hegarty, for instance, was born in 1925 to a single mother (Ruby) and moved to Cherbourg as an infant. First living with her mother in the mothers’ dormitory, from the age of four Ruth was separated from her mother and placed in the Stopford Home for Aboriginal Girls. Hegarty recounts, “When it finally came, Mum was not ready for the separation. How could she be? No mother would willingly give up her child, but mothers were powerless when matron made these decisions.”60 Ruby was sent away to work as a domestic servant and allowed only intermittent contact with her daughter. On the Cherbourg settlement, dormitory living became the norm rather than the exception for Aboriginal women by the 1930s. In these dormitories, white officials sought to discipline and refashion individual Aboriginal female bodies through the training (and taming) of sexuality, hygiene, and labour. Hegarty recalls, The government made every effort to stop us being corrupted by the “forces of evil” supposedly present in the [Aboriginal] camp. We were to [be] kept chaste, it was inappropriate for any of us to have any sexual relationship with the opposite sex. To keep dormitory girls and women from sneaking out to meet their boyfriends, a six-foot barbed wire fence was strung around the dormitory, with very thorny rambling roses growing on it. Native police on patrol kept the watch on the place throughout the night … and the upstairs doors were locked after everyone had gone to bed.61 Unmarried Aboriginal women (when not at work as domestic servants) were kept contained and concealed behind these barbed-wire fences, removed from both Aboriginal and white men.62 Under the new dormitory regime, implemented on Cherbourg, Woorabinda, and Palm Island reserves, it became an offence for an Aboriginal boy or man to “talk to,  wave to, or look at the girls who were institutionalised in the

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dormitory.”63 Those who broke the rules were severely punished; they were whipped, placed in the reserve’s jails, or removed to another ­reserve entirely. Within the dormitories, white matrons endeavoured to erase the sexed bodies of dormitory girls and women entirely. Their heads were shaved, their clothing styles were restricted, makeup was banned, and they were forbidden to talk about their bodies. Menstruation, pregnancy, breasts, and sex were all “dirty” words. Hegarty recalls, “It was dirty to talk about your body. If you named the name you were dirty or talking dirty and you’d get punished for it.”64 The hospital medical examinations, former dormitory residents recall, made them feel profoundly humiliated and ashamed. Most left the dormitories unsure about their bodies, their “things” (menstruation), and the meaning and purpose of sex.65 While white men dominated official debates about miscegenation, the resulting practices – efforts to refashion and manage Aboriginal bodies – were the domain of white women. White settlement nurses and  matrons were charged with the racial reform and uplift of their Aboriginal wards rather than with establishing equity between races.66 A white matron was employed full time from 1933 to manage the Stopford Home for Aboriginal Girls and maintain a “dormitory routine like clockwork.”67 The matron, with the assistance of Aboriginal resident workers, was to ensure that all unmarried women were kept strictly secure within an enclosed environment that came complete with “kitchens, dining halls, workrooms, laundries, lavatories and even a detention ward.” Sleeping areas were kept “securely locked” at night to prevent any immoral behaviour.68 Native police officers patrolled the perimeter and ensured everyone was “put under lock and key.”69 In addition to the physical barriers erected around female dormitory inmates, the matron and community police officers ensured that females were under constant surveillance.70 Albert Holt, whose two sisters were sent to the girls’ dormitory while the rest of the family lived in one of Cherbourg’s cottages, recalled that whenever his sisters needed to visit their parents they required a permit from the superintendent. “The permit was for about ten minutes and they would be escorted by a blacktracker, or community police officer, who would be present for the whole conversation with the parents; nothing was private. When time was up, they were escorted back to the dormitory and put under lock and key.”71 Cherbourg’s male dormitory inmates enjoyed far greater freedom of movement on the settlement. No barbed wire surrounded the boys’ dormitory or the single men’s quarters, and no police escorts were

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r­ equired to accompany them when they left their quarters. However, all Aboriginal people required a government permit to exit the reserve grounds. Dormitory residents led highly regimented lives. Girls were expected to keep high moral standards and to be physically chaste and clean. Cherbourg’s administration used institutional routines such as requirements for regular bathing, daily domestic cleaning tasks, near-constant surveillance, and isolation behind the dormitory’s barbed-wire fence to protect, discipline, control, and purify Aboriginal women’s bodies. The daily routine of the dormitory, especially for older girls, was highly structured and focused on maintaining physical and moral cleanliness through continual and repetitive cleansing. The ringing of bells throughout the day signalled to inmates, a former dormitory girl recalls, “times for meals, work, when to rise and when to go to bed.”72 On rising, all female inmates were required to clean and tidy the dormitories. Duties included making their beds and scrubbing and polishing the bedroom floors every day before school. The kitchen, dining room, bathrooms, and laundry were cleaned and scrubbed twice daily. Even small children were expected to help with cleaning, which served a dual purpose: it helped train girls to be domestic servants, and it ensured that the dormitories were always clean and tidy.73 Training produced discipline: farm labour for boys, sewing and cleaning for girls.74 In the controlled environment of a total institution, Anderson observes, “the most intimate activities of the body and most intimate of human interactions were open to view and for refashioning.”75 Every morning in Cherbourg the matron – the administrator and disciplinarian of the dormitories – inspected all children before school, checking their hair, bodies, and clothing for signs of dirt.76 Girls were required to lift their dresses up so the matron could assess the cleanliness of their bloomers. If any child, boy or girl, was wearing dirty or torn clothing they were required to change it immediately or face punishment.77 The matron was also responsible for supervising the daily “bath parade,” another invasive surveillance technique, in which dormitory girls and unmarried women were communally bathed in front of the matron in a large tub (four or five children at a time) to ensure inmates cleansed themselves properly.78 Queensland government officials viewed cleanliness of both Aboriginal bodies and spaces as a sign of social progress, part of a movement toward modernity. Visiting officials regularly praised the cleanliness of the dormitories. When the deputy chief protector of Aboriginals, Cornelius

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O’Leary, visited Cherbourg settlement in October 1937 he praised the “clean and tidy” appearance of the building.79 Likewise a reporter from the Courier-Mail described the dormitories as “scrupulously clean,” while the Sydney Morning Herald declared the institution “spotlessly clean and well managed.”80 Despite these rituals of hygiene, like other Aboriginal institutions, Cherbourg’s dormitories were overcrowded, and the children were poorly fed, suffered from frequent infectious diseases, had inadequate education, and were given deficient medical care. As Anna Haebich observes, “in place of resources to ensure good health there were endless inspections of bodies.”81 The dormitory’s obsession with cleanliness, Hegarty recalls, “was a bit of a joke because it didn’t matter how we got clean as long as it was not at the extra expense to the government.”82 No toiletries – no soap, shampoo, toothpaste, or toothbrushes – were provided in the dormitories and children were reportedly severely underfed.83 Outside of the dormitories, the matron conducted weekly inspections of all “native cottages” to ensure that married women kept their homes, their gardens, themselves, and their families clean and tidy.84 Those who failed to do so could be fined or be separated from their children (who were removed to the dormitories).

Hygienic Future Workers At the same time as the settlement matron was attempting to cleanse her Aboriginal wards, Cherbourg school’s head teacher, Robert Crawford, was also implementing hygiene practices. In the early 1930s, Crawford began to devise a new school syllabus to use on Cherbourg and other government-run Aboriginal schools. Crawford’s curriculum gave consideration, he wrote, to “the difference in environment and mental ability between the aboriginal child and his white brother.” The new syllabus therefore emphasized practical subjects over “commercial and academic” ones and provided vocational training in manual skills and labouring for boys and domestic science for girls. Crawford also designed a subject entitled “Civic and Morals,” to encourage Aboriginal children to follow a path of “honesty, industry, thrift, care of personal and public property, and recognition of respect due to officials and guardians” and to instill “habits of personal cleanliness and cleanliness of home and settlement generally.”85 As the course title suggests, hygiene practices were inextricably bound to ideas of civic duty and moral standards.86 They were an intrinsic part of what Anderson terms the “rituals of modern citizenship.”87

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Cherbourg’s Aboriginal residents became unlikely subjects of an i­ntensive educational and hygienic reformation that aimed to retrain them (and specifically their children) not for civic responsibility but for  subject responsibility. Cherbourg’s administration constructed hygiene as a duty. Aborigines had to fulfil a duty to themselves, but more significantly they had to fulfil a responsibility to the white staff members of the settlement, their white employers, and white society as a whole. Aboriginal children were expected to be clean for school, not for their health or for the comfort of their fellow students but for the benefit of white teachers. Superintendent “Boss” Semple, in 1938, described the improved cleanliness of Cherbourg’s children as a result of the matron’s daily inspections: “There are few State schools who can show a cleaner lot of youngsters. Gone are the days when the school teachers on the Settlement had to have mixture near them to keep away the smell of perspiring children, th[o]se were the days when there was not a shower provided for the natives.”88 Rather than link cleanliness with health, well-being, or even moral purity, Semple assigned primary importance to the happiness and comfort of his white teachers. As a leading Australian medical historian has observed, “The trajectory from native … to citizen implied a reconfiguring of intimacies with one’s own body and the bodies of others – a remaking of the private.”89 It entailed the realignment away from Aboriginal modes of living and traditional family bonds and toward white conceptualizations of modernity, domesticity, and hygienic citizenship.90 To be Aboriginal and respectable, under the new regime, meant to acquire white standards of  intimacy and shame, hygiene and labour. Aboriginal women’s and men’s bodies were refashioned through technologies of rule – discipline, supervision, and training varied according to location. On arrival at “half-caste” institutions of Western Australia and the Northern Territory, Anna Haebich observes, children were inspected, cleaned, and given clothes to wear. They sometimes received a new name and birth date. This process, dubbed “regrooming,” was designed both to ensure that the children fit institutional standards of hygiene and dress and to “erase vestiges of their former identity and individuality.” Regrooming was central to all total institutions and was the “initial stage of … re-creating each individual anew.”91 Similarly in Queensland’s dormitories, the daily rituals of hygiene and domesticity were part of a  wider program of racial hygiene adopted by the Australian nation to  normalize its population. Rather than being neutral indicators of improved health, hygiene practices were linked to economic and ­

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moralistic concerns at Cherbourg.92 Hegarty remarks, “The dormitory was not only a place to safeguard us, but to train us. It was certainly ­doing its job preparing us for the future by teaching us to respect ­authority, discipline and order, and the importance of neatness and cleanliness.”93 The daily rituals of cleanliness performed by dormitory girls from a young age ensured that they would be competent domestic servants by the age of twelve to fourteen years, at which time the department contracted them out to work for white households. Everything they were taught, former dormitory girls observed, was for the purpose of being useful workers.94 The policing of Aboriginal bodies, the education of Aboriginal minds, and the regulation of Aboriginal reproduction served an economic imperative – to produce clean, tidy, and submissive Aboriginal workers – and a government emblem of Aboriginal advancement. In the context of Queensland, perhaps more than Australia’s other states and territories, the production of labour, disciplining of bodies, and policing of racial divisions were inextricably linked. Cilento mused about the possibility of “solving the native problem in a way that will be to the advantage of the native, and at the same time, will prevent social conflict between white labourers and coloured.”95 Governor Wilson declared in 1934, “It seems far more important to me that [Aboriginal children] should be instructed in practical work than in history or geography. Once they learn to read and write and do simple arithmetic that would seem all that is required.”96 Similarly Robert Crawford observed that all training and education on Cherbourg was designed “to make the native a better aboriginal and not a poor imitation of the white man.”97 Despite official emphasis on retraining Aboriginal bodies and minds, the physical health of Cherbourg’s Aboriginal inmates remained substandard throughout the period. Between 1906 and 1915 one out of every three children born on the reserve did not survive infancy. The infant mortality actually increased during the 1930s and 1940s and was six to seven times higher than the national average. Cherbourg’s infant mortality rate offers considerable insight into the overall health and well-being of the settlement’s Aboriginal community more so than the total mortality rate, as epidemiologists regard infant mortality as the “best single indicator not only of the state of a community’s health but also its economic, social and education[al] situation.”98 Dr Jefferis Turner, director of infant welfare, visited the settlement in late 1936.99 Appalled by the condition of Cherbourg’s children, Turner informed

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Queensland’s under secretary that although the settlement “children … were provided with classrooms and State school teachers, resident nurses, a visiting doctor and [a] hospital … the physical condition of these children [wa]s deplorable.” Turner noted that in his vast experience as a pediatrician, “I am accustomed to the sight of ill-nourished children all over Queensland but only as a minority or as isolated instances. Never before have I seen a whole classroom in which the majority, if not all, of the children were ill-nourished. These children were ill-fed.”100 In response to Turner’s criticisms the Queensland government made no real effort to improve the children’s diet, with Bleakley requesting only that the visiting medical officer weigh the children throughout the year.101 Obviously cleanliness was not the same as health; emphasis was on training above all else. Aboriginal reserves were never intended to isolate Aboriginal people from white society completely but rather to ensure that they interacted with the “right class of whites” through regulated labour relations.102 As Rosalind Kidd has highlighted, the longevity of the Queensland Aboriginal reserve system – established in 1897 and in operation until the 1970s – was more a testament to the financial ­importance of the Aboriginal contract labour than to the government’s commitment to protectionist or reformative policies.103 The Queensland system was not premised on the eventual extinction of the indigenous population, as were the racial absorption policies of the other Australian states and territories, but on the maintenance of the Aboriginal labour force.104 The importance of Aboriginal labour not only necessitated the persistence of racially discriminatory policies but also required officials to expand the racial coordinates of “Aboriginal” to encompass those of mixed descent.105

Conclusion In the interwar period, the state government actively embraced reformatory aspirations to remake racialized and gendered selves and to regulate Aboriginal bodies through regimes of hygiene and the management of reproduction. White officials attempted to reconstitute Aboriginal bodies by imposing disciplinary and regulatory practices that distinguished between women and men. Examples from Cherbourg Aboriginal settlement illustrate the ways in which hygiene and gendered narratives about the intimate figure rearticulated the racial classifi­ cations of interwar Queensland. The “Aboriginal problem” was framed in terms of the need for constant medical supervision, as the state

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attempted to transform the Aboriginal population into useful individualized economic units.106 Patricia Reeves (chapter 1 in this volume) suggests how modes of production constitute meanings of health: in this case the hygiene, rather than the health, of Aboriginal workers took precedence for women in particular as they were channelled into domestic service in white homes. Aboriginal men were at the centre of a paternalistic program to restore their “racial pride” through work, private property, health interventions, and the nuclear family unit.107 Yet it was Aboriginal women as a group who were the primary target of government interventions. Increasingly removed to separate dormitories, subjected to roll calls and police escorts, deemed persistently immoral and oversexed, women were declared simultaneously the most needy and the most unruly members of the Aboriginal population, making them prime candidates for a state program of “medicalization and civilization.”108 For Bleakley and Cilento, discipline, training, medical surveillance, and managed reproduction were different, though complementary, means to the goal of racial uplift. Yet Aboriginal people were never really meant to achieve this goal. The refashioning process produced bodies that were merely “passing” or “second-class citizens.”109 Dormitory women, officials declared, would “always be morally bad” despite the best efforts of staff.110 Aboriginal females remained a perpetually disobedient group requiring ongoing surveillance and regulation. “One has to accept,” Bleakley maintained, that “owing to their nature, and often their temperament, they are over-sexed.”111 Aboriginal males were similarly rendered persistently childlike: “wild hunters” who had lost their “racial pride” and consequently “their proper sense of manhood.”112 In this way the remaking of Aboriginal bodies into suitable subjects and workers for White Queensland was always an incomplete process, which in turn justified government controls. The example of the Cherbourg Aboriginal settlement demonstrates the way in which gender and sexuality, but above all race, determined ideas about health and biological citizenship. Unenfranchised people in the land of their birth, Aboriginal people were corralled into set­ tlements, separated by sex, and taught new regimes of hygiene. The Queensland state’s primary concern remained the health of its white citizens. Outward signs of cleanliness and hygiene took precedence for Cherbourg officials over adequate nutrition for the Aboriginal inhabitants. As a consequence, women saw their children die in conditions where scrubbed floors took precedence over full bellies.

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The history of Cherbourg Aboriginal settlement, like the other histories in this volume, indicates that no community provides a “seamless and coherent moral framework” on which decisions about health and disease are made.113 Instead, opposing ideas, moral judgements, and rationales all influence government legislation, scientific knowledge, treatment strategies, and the behaviour of individuals. The constructions of, and diverse responses to Aboriginal disease indicate how various moral communities provide the boundaries that defined which problems were grounds for concern (and government intervention) and what responses were appropriate. As scholar Randall Albury has suggested, in histories of medicine “changing social concerns are reflected in changing notions of which contributing factor to disease or disability is blameworthy.”114

notes  1 Bashford, Imperial Hygiene, 3.   2  Anderson, “States of Hygiene,” 104.  3 See Evans, A History of Queensland; Evans, Saunders, and Cronin, eds., Race Relations in Colonial Queensland; May, Aboriginal Labour and the Cattle Industry; Robinson, “Full of Passive Resistance,” 175–83.  4 Loos, Invasion and Resistance, 55, 166.   5  Curthoys and Moore, “Working for the White People,” 1–29.   6  The position of “tracker” ostensibly involved traditional Aboriginal skill sets (such as navigation and detection) but in reality the role chiefly ­involved caring for the police horses and other yard duties. Blake, A Dumping Ground, 126–7.  7 Amrith, Decolonizing International Health: India and Southeast Asia.   8  Cooper and Stoler, “Between the Metropole and Colony,” 1–58.  9 Arnold, Colonizing the Body. 10 Vaughan, Curing Their Ills. 11 Kelm, Colonizing Bodies. 12 Shah, Contagious Divides; Hattori, Colonial Dis-ease. 13 Bashford, Imperial Hygiene; Anderson, The Culitvation of Whiteness. 14  Copland, “Calculating Lives.” 15 Kidd, The Way We Civilise, 487; Copland, “Calculating Lives.” 16  Copland, “Calculating Lives,” 384–5. 17  Ellinghaus, “Absorbing the ‘Aboriginal Problem,’” 27, 183–207. 18 Haebich, Broken Circles, 173; Chesterman and Galligan, Citizens without Rights.

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19 Blake, A Dumping Ground, 31–2. 20  G. Arnell to Home Secretary, 24 November 1906, A/31708 06/6962 (Brisbane: Queensland State Archives [hereafter Q S A ]). 21  Raphael Cilento, “Report of a Partial Survey of Aboriginal Natives in North Queensland October–November 1932,” series 1928/1, control 4/5, barcode 141738 (Canberra: National Archives of Australia [hereafter N A A ]), 22. 22 Ibid. 23  J.W. Bleakley, quoted by Rosalind Kidd, “Regulating Bodies,” 362. 24  “Annual Report of the Chief Protector of Aboriginals,” Queensland Parliamentary Papers [henceforth Q P P ], 1, 1933, vol. 1, 9–10. 25 Bleakley, The Aborigines of Australia, 178. 26  The Chief Protector of Aboriginals’ Office was renamed the Department of Native Affairs in 1934 and placed under the administrative umbrella of the Department of Health and Home Affairs, which also administered the Department of Health. Kidd, The Way We Civilise, 80–115. 27  Letter: Raphael Cilento to Phyllis Cilento, 28 May 1932, Raphael Cilento Papers, U Q F L /44, box 26, Fryer Library, Brisbane. 28  Deputy Chief Protector, 8 July 1935, quoted by Kidd, “Regulating Bodies,” 335. 29 Hegarty, Is that you Ruthie?, 118. 30  South Burnett Times, 10 Febuary 1933. 31  Courier-Mail, 18 October 1933. 32  Parsons, “Defining Disease, Segregating Race,” 85–114. 33  Chief Protector to Protector of Aboriginals, Windorah, 23 July 1937, A/58686, Q S A , Brisbane. 34 Hegarty, Is That You Ruthie?, 118. 35  Cilento, “Report of a Partial Survey,” 22. 36  Ibid., 2. 37  Anderson, “States of Hygiene,” 105. 38 Bleakley, The Aborigines of Australia, 124. 39 Ibid. 40  Goodall, “Assimilation Begins at Home,” 77. 41 Holt, Forcibly Removed, 68–9. 42  Cecil Cook to A. H. Baldwin, 15 February 1926, SP1061/1. 94/2, N A A , Canberra. 43  Haskins and Maynard, “Sex, Race and Power,” 206. 44  Paisley, “Race Hysteria, Darwin 1938,” 43. 45  The Commission of Crown Lands, cited by Reynolds, With the White People, 90. 46  Department of Health and Home Affairs, 1938.

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47 Bleakley, The Aborigines of Australia, 124. 48  Leslie Wilson to Mr Pearse, 6 June 1936, A/68584, series 4319, item 336209, Q S A , Brisbane. 49 Ibid. 50  Folder: Register of Removals 1900–1935, A/69528, series 1801, Q S A , Brisbane; Folder: Cherbourg – Removals (1930s–1940s), A/55334, ­series 4320, item 714670, Q S A , Brisbane. 51  Folder: Cherbourg – Removals (1930s–1940s), A/55334, series 4320, item 714670, Q S A , Brisbane. 52  Anderson, “States of Hygiene,” 110. 53 Ibid. 54  Chief Protector to Under Secretary, 6 December 1922, A/31708, 22/9880, Q S A , Brisbane. 55  Q P P , (1926), vol. 1, 1018; Chief Protector to Under Secretary, 30 November 1934, A/68584, Q S A , Brisbane. 56  Q P P , 1928, vol. 1, 941. 57  Q P P , 1912, vol. 2, 1015–16; Q P P , 1928, vol. 1, 941; Q P P , 1934, vol. 2, 886; O. Shimmin to Chief Protector, 6 February 1934, A/31710, 34/11056, Q S A , Brisbane. 58  O. Shimmin to Chief Protector of Aboriginals, 10 October 1934, A/31710, 34/11056, Q S A , Brisbane; Blake, A Dumping Ground. 59 Ryan, Civic Wars, 296. 60 Hegarty, Is That You Ruthie?, 26. 61 Ibid., 57. 62  Leslie Wilson to Mr Pearse, 6 June 1936, A/69584, Q S A , Brisbane. 63 Holt, Forcibly Removed, 81. 64  Ruth Hegarty, cited by Haebich, Broken Circles, 404. 65 Haebich, Broken Circles, 404; Lesley Williams, Submission to the Senate Committee Inquiry into Stolen Wages, http://www.aph.gov.au/~/media/ wopapub/senate/committee/legcon_ctte/completed_inquiries/2004_07/ stolen_wages/submissions/sub82_pdf.ashx (accessed 14 June 2011). 66  Stoler, “Tense and Tender Ties,” 850. 67  The Aboriginal staff involved in the running of the dormitories included Aboriginal managers, cleaners, minders, and cooks. See Huggins and Huggins, Auntie Rita, 29. 68  Chief Protector to Under Secretary, 30 November 1934, A/68584, Q S A , Brisbane. 69 Holt, Forcibly Removed, 13. 70  Chief Protector to Under Secretary, 30 November 1934, A/68584, ­series 4319, item 336209, Q S A , Brisbane.

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71  Albert Holt, a former Cherbourg resident, recounts his experiences living on Cherbourg settlement in his memoir. Holt, Forcibly Removed, 13. 72 Hegarty, Is That You Ruthie?, 21; also see Attwood, “Space and Time at Ramahyuck,” 41–54. 73  Chief Protector to Under Secretary, 30 November 1934, A/68584, Series 4319, item 33620, Q S A , Brisbane. 74  Raphael Cilento, Report of Inspection of Palm Island, Mona Mona and Yarrabah, Feburary–March 1937, A/58861, Q S A , Brisbane. 75  Anderson is drawing on Erving Goffman’s concept of the total institution. Anderson, “States of Hygiene,” 110; Goffman, Asylums. 76  Office of the Chief Protector of Aboriginals, Duties of Settlement Matron, 21 July 1936, A/58816, item 336685, Q S A , Brisbane; Acting Superintendent of Cherbourg Aboriginal Settlement to Chief Protector of Aboriginals, 7 February 1938, A/58683, series 18090, item 336207, Q S A , Brisbane. 77  Acting Superintendent to Chief Protector, 7 February 1938, A/58683, ­series 18090, item 336207, Q S A , Brisbane. 78  Office of the Chief Protector of Aboriginals, Duties of Settlement Matron, 21 July 1936, A/58816, item 336685, Q S A , Brisbane; Hegarty, Is that you Ruthie?, 36–40. 79  R. Holmes to Chief Protector of Aboriginals, 8 April 1937, A/3908, 37/3672, Q S A , Brisbane. 80  Courier-Mail, 3 April 1937; Sydney Morning Herald, 21 November 1936. 81 Haebich, Broken Circles, 403. 82 Hegarty, Is that you Ruthie?, 55. 83  Raphael Cilento, Australian Institute of Anatomy, The Anne MacKenzie Oration for 1933 by Raphael Cilento, Raphael Cilento Papers, U Q F L /44, box 26, Fryer Library, Brisbane. 84  Superintendent to Chief Protector, 10 September 1929, A/58677, Q S A , Brisbane; Suggested Duties of Visiting Medical Officer Barambah, September 1929, A/58677, Q S A , Brisbane; Holt, Forcibly Removed, 13. 85  Robert Crawford, General Scheme of Work for Aboriginal Schools Situated on Government Aboriginal Settlements, Elkin Papers, 1/12/223, University of Sydney Archives; Crawford was assisted in his teaching duties by Aboriginal assistants including Janie Sunflower who taught music and physical education. 86 Hattori, Colonial Dis-ease, 192. 87 Anderson, Colonial Pathologies, 660, 718. 88  Acting Superintendent to Chief Protector, 7 February 1938, A/58683, ­series 18090, item 336207, Q S A , Brisbane.

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  89  Anderson, “States of Hygiene,” 110.  90 Bashford, Imperial Hygiene, 3.  91 Haebich, Broken Circles, 343.  92 Hattori, Colonial Dis-ease, 192.  93 Hegarty, Is that you Ruthie?, 54.   94  Huggins and Huggins, Auntie Rita.   95  Cilento, “Inspection of Palm Island, Mona Mona and Yarrabah, FebruaryMarch 1937.”   96  Wilson quoted by Blake, A Dumping Ground, 65.   97  Crawford quoted by Blake, A Dumping Ground, 67.  98 Gordon, Health, Sickness and Society, 141.   99  A. Jefferis Turner to Under Secretary, Home Department, 2 December 1936, A/3939 37/9222, Q S A , Brisbane. 100  Thearle, “Turner, Alfred Jefferis,” 288–9; A. Jefferis Turner to Under Secretary, 2 December 1936, A/3939 37/9222, Q S A , Brisbane. 101  J.W. Bleakley to Under Secretary, Department of Health and Home, 20 September 1937, A/3939 37/9222, Q S A , Brisbane. 102  Quoted by Kidd, “Regulating Bodies,” 254. 103 Kidd, The Way We Civilise. 104  Ahmed, “She’ll Wake Up Of These Days,” 87–107. 105  Ibid., 91–2. 106  Cilento, “Report of a Partial Survey.” 107  Department of Health and Home Affairs, What is their Destiny? (Brisbane: Government Printer, 1938), 1. 108  Anderson, “States of Hygiene,” 110. 109 Ibid. 110  Superintendent Memorandum to Chief Protector, 8 April 1935, A/58687, Series 18090, Item 336217, Q S A , Brisbane. 111  Q P P , 1934, vol. 1, 884. 112  Department of Health and Home Affairs, What is their Destiny?, 1; Horace Tozer, “Measures Recently Adopted for the Amelioration of Aborigines,” Votes and Proceedings of the Legislative Assembly (Queensland), 1897, vol. 2, 723–38. 113  Robertson, “In a State of Corruption,” 11. 114  Albury, “Cause, Responsibility and Blame in Disease and Disability,” 19.

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4 Shaping Student Bodies and Minds: The Redefinition of Self at EnglishCanadian Universities, 1900–60 C at h e r i n e G i d n e y Universities are typically associated with the shaping of young minds. Yet in the first half of the twentieth century, educators and health experts became increasingly concerned about the health of students’ bodies. At many institutions, administrators began to hire a host of experts – dieticians, nurses, doctors, and physical educators – to supervise students’ health. They frequently instituted compulsory medical examinations for all students and one to two hours of physical training a week for first- and second-year students.1 They also set up infirmaries and provided access to doctors throughout the year, and by the 1920s they had introduced hospitalization insurance in some places. Health experts and educators saw their role as to identify and quarantine the contagious, evaluate fitness and provide advice about physical exercise, and inspect and pronounce upon proper living conditions, dining, clothing, and behaviour. The goal of university health programs was broad: to maintain a healthy campus and to help improve student health. In taking on these tasks, doctors, deans, and physical instructors, who were all working outside the academic stream of the university but still within a formal educational setting, in contrast to their counterparts in the programs described in the other chapters in this section, played an influential role in shaping student bodies and student life more generally. This attention to health was prompted by a broader concern on the part of university officials to ensure that students left university fit in mind, body, and spirit. Canadian historians have for some time focused on the role of the university in students’ intellectual and moral formation and

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development.2 They have paid much less attention to the role that ideas about health played in that process.3 One aim of this chapter, then, is to illuminate the ways in which health concerns were integral to the aims and purposes of student formation. Historians who have examined the role of universities in student development have generally focused on the process of character formation around the turn of the century. The notion of character was rooted in the middle-class evangelicalism, and later liberal Protestantism, of the university constituency. At its core, the aim of character development was self-sacrifice: sacrifice to one’s team, one’s family, one’s community, and one’s country. While historians have illuminated the values and attributes embodied within the term character in the late nineteenth and early twentieth centuries – something we’ll return to in a moment – little is known about the nature of student formation in later decades. Indeed, by the mid-twentieth century, the language and ideals of character were waning. Educators, and the public at large, influenced by the rise of psychology and increasing concerns about mental health and personal adjustment, began to adopt the discourse of personality. In doing so, they focused on self-realization: the development of an individual’s specific characteristics and traits to provide that individual with the greatest chance of fulfilment and success. Attention to the period after the Second World War, then, will reveal the ways in which changing beliefs about “good health” helped to reshape educators’ notions about the aims and purposes of student formation. The gradual shift from a focus on character to one on personality, I argue, was not simply a matter of terminology. Rather it represents a more fundamental change in societal values and beliefs about the nature, meaning, and development of self that would have far-reaching ramifications. Historians have shown the way in which educators and parents drew on many of the new psychological ideas to understand child development and find more modern strategies for raising and training children to become productive citizens. In the process, they argue, these new ideas contributed to, and reinforced, the domestic and gender conformity of the era.4 Yet, as Doug Owram has suggested, that culture of domesticity also fertilized the seeds of change: new psychological and educational ideals focusing on child-centredness and the importance of experience and self-development, along with an antiauthoritarian approach in child-rearing and educational practice, would influence the social and cultural upheaval made manifest in the late 1960s.5 How exactly that process occurred still requires elucidation.

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Within universities the shifting ideals from character to personality provide one means of better understanding this development. That shift in language had particular implications for women. First, it occurred alongside an increasing specialization and fragmentation of knowledge and differentiation of disciplines, both within the health arena and in the university more generally. The effect of this was to elevate expertise – a development that gave status to both male and female health professionals – while consolidating health services and solidifying disciplines in ways that tended to place female health professionals under male supervision. Second, within the context of the university, the discourse of personality articulated a new conception of women’s place on campus. In the nineteenth and early twentieth centuries, character formation referred to the development of manhood and womanhood. From the 1940s on, as educators adopted the discourse of personality, they subsumed those gendered ideals under the broader, ostensibly less gender-specific concept of the student. At the same time, the focus on self-realization allowed student formation to be reoriented away from the notion of self-sacrifice as defined by Anglo-American Christian society and toward the possibility of developing individual value and belief systems. An examination of educators’ shift in discourse from an emphasis on character to a focus on personality can thus reveal the ways in which university officials incorporated contemporary ideas about health, as well as gender and citizenship, within their aims of student formation.6 I employ an intellectual and social history approach in my exploration of the meaning of health, attempting to illuminate the ways in which educators translated their specific ideas about health into actual practices. Examining the shift from character to personality in this manner sheds some light on the process by which health experts and university staff helped re-envision the ideal student in the twentieth century.

T h e I n t e r n at i o n a l a n d C a n a d i a n C o n t e x t of Health Concerns In the second half of the nineteenth century, Anglo-American society enthusiastically embraced organized sport and physical culture, equating the disciplined and healthy body with national health and stability. Various societal developments and concerns provided the impetus: an emerging and insecure middle class attempting to assert its ideals as dominant, anxiety about the new values of industrial capitalism and the

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negative effects of white-collar work on masculinity, increasing support by moral reformers and Protestant churches for morally uplifting amusements in an effort to stave off the intrusions of secular culture, and a turn toward muscular Christianity and a cult of the strenuous life in reaction to the perceived feminized domesticity of the period.7 These developments coincided with an emergent public health movement. Health experts’ attempts to sanitize city streets led them to focus on public institutions such as schools, not only as sites of epidemics but as a cause of ill health. Many educators and health reformers began to advocate, and school authorities to sanction, a range of medical and health initiatives such as physical exercise, medical examinations, compulsory vaccination, the inspection of school buildings and grounds, and the introduction of health topics into the school curriculum.8 Growing anxiety about the health of university students coincided with the acceptance of women into university. In the 1870s and 1880s, as women fought for and gained access to higher education, they faced a barrage of criticism about their physical and mental capacity to study as well as about the effects of this education, especially on their reproductive organs. Opponents of women’s education argued that mental strain led to nervous disorders and reproductive failure, as energy was drawn from the reproductive system to the brain. Proponents argued that supervised physical activity would counter this problem by maintaining a proper balance between physical and mental exertion. Reservations about women’s ability to undertake a difficult course of study continued into the early decades of the twentieth century.9 Administrators did not worry about only women’s health. By the turn of the century they expressed increasing concern about male students as well. Whereas university leaders had often turned a blind eye to student antics in the nineteenth century, by the end of that period they had become keen to contain student behaviour.10 Many grew alarmed about the violence and brutality of college sports. This was particularly true in American universities, where athletic facilities and team sports had expanded significantly. By the early twentieth century, some university authorities, faculty members, and alumni had begun to voice strong concerns about athletic injuries, the elevation of sport above academic purpose, and its increasing commercialism, concerns that carried over into the Canadian context.11 Educators at the turn of the century embraced physical culture and health practices more generally, not only to ensure physical health but thereby to encourage mental vigour and moral fortitude. However, as

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several chapters in this volume document – such as Patricia Reeve’s discussion of workingmen in antebellum United States and Tracy Penny Light’s examination of the discourses of twentieth-century cosmetic surgery, to name just a couple – educators and medical experts articulated ideals of health differently for men and women. Amateur sport and physical exercise had been conceived first as a means of creating and regenerating manhood, and proponents believed these could impart habits and virtues such as “fair play, physical hardiness, physical and mental well-being, courage, endurance, teamwork, efficiency, self-restraint, innovation, competitiveness, and respect for others.”12 Educators perceived such values as capable of instilling in men the characteristics needed for participation in industrial society, national regeneration, and imperial conquest.13 Female educators quickly perceived physical culture to be equally valuable for the creation of womanliness. They trumpeted many of the same civic virtues, seeing games and sports as providing women with qualities such as organizational skills, discipline, respect for authority, determination, self-reliance, self-control, selflessness, teamwork, and service to others. The exercises they recommended, however, were less strenuous than those for men and the ideology accompanying physical culture reinforced women’s primary role as mothers.14 In endorsing broader societal ideals, North American educators came to perceive physical culture as another means, beyond the curriculum or the moral and religious environment of the university, of shaping students’ character.

Instilling Character in Canadian Students, 1920s to 1940s Canadian university administrators introduced compulsory physical training and medical examinations in the early decades of the century for women living in residence and men involved in intercollegiate athletics. These initiatives became more formalized and more widely disseminated between the 1920s and 1940s. Although the overall program was aimed at all students, ideas about health and morality ensured that it was tailored to gendered ideals. Administrators, educators, and concerned citizens perceived a need to keep female health and morality under surveillance and protected. Thus, for example, in some cases physicians and others examined not only students’ bodies but also their living environments. In the 1920s, administrators and alumnae at the University of Toronto raised the alarm over women’s living conditions,

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highlighting the negative moral effects for women living in mixed-sex boarding houses as well as overcrowding within single-sex housing. In the latter case they criticized the sharing both of double beds in boarding houses and of small residence rooms.15 The lack of proper cooking facilities or provision of meals within boarding houses also raised concerns. Belief in the etiquette and moral influence of the dining room held for both men’s and women’s residences. Yet it was more explicitly laid out for women. A sit-down dinner should go beyond provision of a nutritious meal to train students in dining etiquette, the art of polite conversation, and general comportment for public life. The dining room was perceived as an essential component of the women’s residence hall: a place where students could gain the refinement and cultivation deemed necessary for their future endeavours and their place as the wives of the future leaders of the nation.16 The idea that women required greater protection than men arose, too, in medical examinations themselves. For many students of the early twentieth century, a medical examination was a new experience. Examinations occurred at separate locations for men and women; female ­doctors examined female students, and male doctors attended male students. In both cases students lined up, met with a nurse, and were then sent in for a checkup with the doctor. At some institutions male students appeared nude before the doctor, but female nurses and doctors attempted to ensure a modicum of propriety for female students, allowing them to remain in bloomers and providing them with a vest for the upper body.17 If administrators and physicians treated womanhood with delicacy, they assumed a form of masculinity that accepted not only male nudity but also active male sexuality. Where full health programs existed, both male and female students received some talks on health issues such as social hygiene (or venereal disease), heredity, eugenics, and the “origins of life.” In addition, medical staff in some instances tested men (though not women) for venereal disease. Concern about venereal disease gained force with the testing of soldiers for syphilis during the First World War and consequent discovery of high rates of infection.18 In the United States, this led to post-war federal funding of social hygiene programs in a variety of colleges and universities.19 Some medical officials in Canada began testing male students for syphilis in the early 1920s, and both compulsory and voluntary testing became more common by the 1940s.20 Though some differences in the treatment of men and women were  evident in health inspections of living conditions and medical

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examinations, gender differences appeared most frequently in assigned physical activities. Female physical educators combined an emphasis on gymnastics with folk dances and sports. Instructors also introduced female students to both individual and team sports. As in Britain and the United States, physical educators in Canada commonly focused on sports considered appropriately feminine, such as captain ball, centre ball, basketball, tennis, and field hockey, in which participants could learn skills while avoiding physical contact or aggressive play.21 Physical educators also focused on improving female posture and carriage through classes on deportment and proper habits of sitting, standing, and walking.22 Moreover, as Martha Verbrugge notes for the American context, many of the first female physical educators not only aimed to create “ladies” but “modeled femininity” through their own appearance and behaviour.23 In general, it was only with the onset of the First World War that universities instituted compulsory exercises for men, in the form of military drill. Some institutions established compulsory programs after the war and, as was the case with women, these included various forms of gymnastics and individual and team sports.24 With the outbreak of the Second World War, administrators re-formed Canadian Officers’ Training Corp (C O T C ) units, many of which had become ­dormant after the First World War, and instituted compulsory military training for physically fit male students either in the C O T C or in an auxiliary corps.25 As in educational institutions in the United States and Britain, the aim of physical training and medical examinations was both to ensure a healthy student body and to aid in administrators’ broader task of character formation. Physical educators drew on training systems that ­reflected and reinforced the ideals of manhood and womanhood that they hoped to instill in students. The virtues and values they considered important were strikingly similar to those historians have fairly ex­ tensively identified as developing with the rise of nineteenth-century ­middle-class amateur sport. In an article published in 1923, for example, A.S. Lamb, physical director for men at McGill University, noted the importance of physical education in developing qualities in men such as “initiative, leadership, honesty, loyalty, courage, self-control, modesty in victory, fortitude in defeat.”26 In a companion piece, Ethel Cartwright, physical director for women at the same institution, argued that physical education was important for girls and women as it created “self discipline, self control, self reliance, unselfishness, honesty, loyalty, habits of ready obedience, co-operation, a spirit of service overshadowing a

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spirit of gain.”27 Educators also believed physical culture contributed to mental prowess, spiritual maturity, and the training necessary for both male and female students for the next step in their life, that of becoming productive citizens.28 As a 1940 memorandum on physical education at McGill stated, “Youth is the period in which habits are formed that will materially affect the health status of our future citizens.”29 Still, women fit rather uneasily into this vision of citizenship. Progressive educators in the first decades of the century vacillated between focusing on the benefits of physical education for women’s future role as mothers and its benefits for their participation in the workforce and in public life. The nineteenth-century notion that women had an important role as guardians of the race remained prominent in university administrators’ rhetoric in both French and English Canada well into the twentieth century.30 Yet motherhood was never the only, or even dominant, discourse on university campuses. In the 1920s, students still debated women’s role in society and newspaper articles still reflected male students’ unease with the educated woman. Still, public discourse more and more often reflected support for a woman’s right to choose a career over motherhood.31 Moreover, most female educators, medical officers, and administrators were single women. Though they often advocated marriage and motherhood first, they also recognized that at least some women would need to provide for themselves – indeed, they symbolized this possibility in a very tangible way.32 More middle-class women remained single or held jobs before marriage, although the number of women choosing these options was still low. Their numbers would increase through the first half of the twentieth century. Women professionals thus emphasized the importance of physical training for a robust mental and physical constitution. They also emphasized the importance of physical training to “earn wages” or, more vaguely, as a “value to a citizen in whatever part of life he or she treads.”33 By the early decades of the twentieth century, physical training and health education had become new means by which educators hoped to instill and reinforce character. For both men and women, the ­emphasis was on personal development through the sublimation of self in the service of others and ultimately of the nation. Historians have found that in practice the sacrifice for women would occur in the family and community and, less frequently, in a career oriented in those spheres. For men it would extend to the physical defence of the nation.

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T h e S h i f t t o P e r s o n a l i t y, 1 9 3 0 s t o 1 9 6 0 s Even as student health services and physical culture became established on campus, programs and emphases had begun to shift. In places such as the University of Toronto and McGill University, where physical education and health services had been bound together fairly tightly, these areas gradually began to separate. In the years after the Second World War, physical educators, wishing to assert their expertise and advance their specialties, fought for the creation of departments, schools, or faculties on the same grounds as other disciplines. As health services grew, they too developed their own infrastructure.34 Both were also being reshaped by new priorities. Physical training, for example, was being reconfigured by new ideas. In the physical training programs of many universities, core elements such as gymnastics, sports, and games remained central well into the 1950s, yet even in the interwar years other emphases began to appear. The aims and ideals of progressive education – that is, schooling focused on training in activities useful for everyday life, and placing the interests and needs of the child at the centre of the educational enterprise – began to gain influence.35 For example, physical educators began to de-emphasize gymnastics in favour of learn-to-swim programs, to offer more varied activities, and to place more emphasis on physical and motor ability tests.36 While men’s and women’s programs remained separate, the earlier concentration on such things as posture, deportment, and light gymnastics in women’s programs began to disappear. By the 1960s, some institutions offered most activities to both men and women.37 Thus, while students continued to engage in physical training in separate classes, gender differentiation between the activities in their programs lessened. Health services, too, began to develop new priorities. Physicians focused less on environmental and moral improvement and more on the prevention and treatment of disease. The North American attempt to eradicate tuberculosis in the decades after the First World War, and the accompanying financial resources dedicated to that project, led campus health services to focus enormous energy on that issue. Beginning in the 1940s and continuing into the 1960s, most institutions required mass tuberculosis testing, with significant numbers of students also undergoing a chest X-ray.38 The focus on tuberculosis helped further a differentiation between experts and lay people. Historians have noted this phenomenon in other contexts. Activities such as social hygiene and civic improvement, which had their roots in broad-based social

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reform movements, gradually gave way to direction by experts. Efforts to eradicate tuberculosis aided that development within universities, a process that would intensify after the Second World War. Even as medical experts focused attention on tuberculosis in the 1930s and 1940s, calls could be heard for the work of university health services to expand beyond the physical body and encompass mental health. These new concerns arose with the development of psychology as a discipline.39 In the early twentieth century, psychologists began to re-categorize mental illness from being a hereditary affliction to one with both mental and environmental causes. In doing so they shifted from the language of nerves or neurasthenia – a weakness inherited by a few – to neuroses, which could develop in anyone.40 That emphasis on prevention and treatment of maladjustment would give psychologists an important role in educational settings. In the 1920s, some American colleges and universities began hiring psychologists to provide counselling and in some cases to teach courses in mental hygiene.41 With Canadian universities having fewer resources than their counterparts in the United States, the inclusion of psychologists and psychiatrists in student health was slower in Canada. In the 1920s and 1930s, some larger universities possessed sufficient resources to send a few students to consult an expert. Beginning in the 1930s, and more frequently in the 1940s and 1950s, university health experts began to call for greater resources to be devoted to mental health. Their voices would be joined in the early 1960s by those of students demanding general counselling and psychological services.42 Although the incorporation of psychologists into the university health system would be slow, ideas about neuroses, maladjustment, and the importance of personality development made deep inroads into the popular imagination during the war and in the post-war years.43 In the 1930s and 1940s health experts, physical educators, and university administrators began to turn their attention from the concept of character to that of personality. Initially they did so by mixing the older ­ideals of character with the newer language of psychology. In some cases, they employed old and new terms interchangeably. In 1938–39, for ­example, S.A. Korning, associate professor of physical education at Dalhousie University, described the aims of that institution’s physical education program as follows: “The physical education achieved in games and other activities is valuable as a development of personality, in that the physical exercises give to the practisers not merely physical development, but also the development of valuable qualities of will and

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character. The designation ‘physical education’ is in reality too narrow, because in teaching the participants how to use the body and how to master it, the physical exercises have the effect of cultivating the whole personality. This is not physical education, but an education by physical means.”44 Korning thus equated the cultivation of personality directly with the development of will and character. Other educators simply replaced the term character with personality. In 1934–35 Robert Falconer, former president of the University of Toronto, stated, “The University is at once a source of individual culture and of public service. It deepens and enriches personality, and through the enriched personality of its members it can be a servant to the whole nation.”45 Similarly, in his 1935–36 annual report, the principal of McGill University stated, “While a university exists as a training ground of skillful workers it must remember that the first need of society is the production of men and women not merely stored with factual knowledge but trained to think and to judge: men and women moreover whose personality is physically, intellectually and spiritually developed to the utmost capacity.”46 In these cases leading university administrators adopted the more up-to-date language but applied it in a way that would have been entirely familiar to those who spoke about the idea of character in earlier decades. By the 1940s and 1950s, the terminology of personality was widely accepted by university administrators. Contemplating the creation of a required program in physical education, a senate committee at McGill University noted in 1944 that “the Department of Physical Education considers the student to be a young, vigorous active total personality, with all his functions cooperating harmoniously for buoyant, healthful living.”47 Keith King and Angus Gillis, co-directors of the Physical Education Department for Men at Dalhousie University, argued in the early 1950s that physical education was “an essential agent for the development of the proper attitudes and the intangible factors required for wholesome living.” They went on, “There is no other activity that offers the opportunity that Physical Education offers in learning such intangible factors as safety, living with others, and respect for authority … Our aim is to help the University build a wholesome, well-rounded citizen.”48 Zerada Slack, director of physical education for women at the University of Toronto, noted in a report to the president in the early 1950s that “it is the aim of modern Physical Education for women to make some contribution to the development of the student as a whole person; it contributes, that is, not only to her organic health but also to

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her expanding personality.”49 Near the end of the decade, she wrote in an article in Health magazine, “Physical education is a service programme which has as its aim the development of mentally, emotionally and organically sound citizens through skills, games and physical activities.”50 The emphasis on personality development formed part of educators’ increasing adherence to the ideals of progressive education. As a result, they attacked what they perceived to be the regimentation of traditional forms of physical education and learning methods more generally. Maurice Lewis Van Vliet, who became director of the Department of Physical Education at the University of Alberta in 1945, wrote in an article on physical education during wartime, “We plan to promote opportunities for mental expression, encourage creative thinking and develop personality, and do not believe in training our young people to memorize a few set exercises … University students should not be forced to educate the physical but should be educated through the physical.”51 A decade later Zerada Slack noted, “Since individuals differ, physical education must” as well: “The student is no longer expected to fit into a regime characterized by large numbers doing the same thing at the same time. On the contrary, in a modern programme, classes are smaller, the programme offers greater variety, and the activities are selected for their value to individual students. Personal development of the student is sought first, with motor skill and strength coming second.”52 By the post-war years, then, educators commonly used the language of personality. They spoke and wrote of creating a “total personality,” developing the student “as a whole person,” and building a “wellrounded citizen” in the effort to promote, among other things, “healthful living,” “safety, living with others, and respect for authority,” and “creative thinking.” The emphasis on personality had the effect of drawing their attention to the individual adjustments that students needed to make to find their place within society. Inner harmony would facilitate societal cooperation, and inner development would allow an individual to fulfill their full social potential. Individual difference was also emphasized. There was no one way to find inner harmony, to discover one’s place in society, or to complete one’s development, the practical implications of which required the recognition of difference within physical education programs. Into the 1960s, then, universities continued to focus on training students’ bodies, but not in the same way they had in the 1890s. The changes both in the nature of programs and in ideology had two major

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implications for women in particular. First, they affected the authority of female staff. The effects of heightened medical authority, which became apparent with physicians’ attempts to eradicate tuberculosis and was consolidated with the turn toward mental health, involved a process of differentiation between experts and lay people. At the same time, within the university, health services and physical education became ­increasingly divided as those involved in both areas attempted to professionalize their respective fields. One result was that the earlier phenomenon – whereby, particularly in women’s residences, deans, physical educators, and doctors worked together to ensure the moral, mental, spiritual, and physical health of students – gave way to a separation of roles. By the middle decades of the twentieth century, deans of women and physical educators had ceased to lead discussions on medical subjects and, equally, doctors made fewer pronouncements about general living conditions. As each arena professionalized, a process of consolidation often occurred. In Canada, just as Martha Verbrugge points out for the United States, when institutions merged historically separate male and female physical training or health services units, the new ­hierarchical structure comprised a male director supported by a female associate director.53 In the process, women who had been part of a medical discussion, such as deans, were excluded, and female experts who had held leading positions at least in women’s residences came under male supervision. Second, the move away from character and toward personality had significant implications for the construction of students’ gendered identities. Character was about the creation of manhood and womanhood. At least on the surface, personality was more gender neutral and focused on creating individuals and citizens. In their emphasis on developing personality, educators used language that did not differentiate between men and women but rather centred on students as individuals. The change obviously did not institute gender equality. In the 1950s, traditional gender roles remained prominent, as illuminated in the chapters in this collection by Wendy Mitchinson, Thomas Wendelboe, and Mona Gleason and Anika Stafford.54 On campus, men and women had unequal access to athletic facilities and their programs remained different. In residence, female students continued to be seen as in need of pro­ tection while female professionals on campus assumed roles subordinate to those of men. At the same time, however, over the decades, women made gains on campus. While they continued to face restrictions on their behaviour throughout this period, they also experienced a gradual

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liberalization of rules and regulations and greater integration into many extracurricular activities.55 The shift from character to personality was a subtle reflection of a reorientation of women’s place on campus. In using the language of personality, educators subsumed womanhood under the rubric of personhood. The shift to a more superficially gender-­ neutral language would, over the long haul, allow sexism to remain in less obvious, but more insidious, forms. Yet educators’ use of this new discourse may provide one clue as to how and when women’s place on campus was reconceptualized over the course of the twentieth century. The increasing prevalence of the concept of personality has generally been perceived in a negative light, as connected to the rise of a therapeutic culture, a cult of personality, and a focus on individual self-­realization: the development of a cultural or societal focus on the individual self.56 Whereas in the early part of the century educators clearly connected the habits and values associated with character development to broader notions of self-sacrifice, those who turned to the language of personality seemed less inclined to elucidate the links between individual development and the duties of citizenship. On the one hand, the development of personality, like the formation of character, could be understood within a Christian framework. This was certainly the interpretation that dominated at mid-century. Yet the idea of personality development could also offer alternative visions of living one’s life. In rejecting what they perceived to be the regimentation and regime of traditional programs in physical culture, Maurice Van Vliet and Zerada Slack echoed a much broader critique of the nature of education emerging in the 1940s and 1950s, one offered by adherents of the progressive education movement. While Van Vliet and Slack probably perceived freedom of self-­ development as the best means of equipping students for their societal role, by the early 1960s the occasional commentator could be heard disputing even that belief. At a 1963 conference on student mental health, Pierre Dansereau, dean of the Faculty of Science at the University of Montreal and chair of the conference, went so far as to say, “We do not train students for good citizenship or to fit themselves to an existing social pattern. No, we get together to criticize this pattern.”57 By the mid- to late 1960s, then, the idea of developing one’s personality and the focus on self-fulfillment could promote alternative modes of being, new forms of masculinity and femininity, and new ways for both men and women to understand their roles as citizens. By the late 1960s, many young men and women would turn to an interpretation of

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individual identity that included a fundamental critique of societal ­values and government policies.

Conclusion Between 1900 and 1960, educators’ notion of self was redefined in subtle but transformative ways. This process occurred within the context of health imperatives aimed at fostering the full development of students so that they might fully contribute to the social fabric. However, whereas in the early twentieth century educators linked good health to one’s ability to serve the Christian community and nation, by mid-century their attention had been redirected to the realization of the self. This was a less precise aim but may also have helped to facilitate gradual ­acceptance of a variety of interpretations of gender ideals and forms of citizenship. Historians have focused on the role of universities in promoting students’ moral, spiritual, and intellectual development. Yet ideas about health and health practices have also been a central, and overlooked, factor in student formation. The shift in language from character to personality illuminates the intersection of ideals of gender and health on campus as well as the ways in which changing health priorities have helped to reshape gender ideals. In adopting a new language and new priorities, health practitioners and educators not only engaged in activities that reflected broad social and intellectual change but also participated in that transformation. While administrators in the 1970s and 1980s would continue to promote the idea that the university had a role in creating well-rounded citizens, the meaning and nature of that citizenship was qualitatively different from what it had been in the early decades of the century.

Acknowledgments The research for this article was funded by Associated Medical Services Inc. (Hannah Institute) and the Social Sciences and Humanities Research Council of Canada. I thank Bruce Curtis, Ian Nicholson, Carey Watt, and the anonymous reviewers and editors of this collection for their helpful comments on earlier versions of this chapter. This article draws on material from Catherine Gidney, Tending the Student Body: Youth, Health, and the Modern University (University of Toronto Press, 2015). Material used with permission of the publisher.

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notes   1  Medical examinations and physical training appeared in women’s residences at McGill University and the University of Toronto in the first ­decade of the twentieth century and were instituted for men at the University of Toronto in 1920. They became compulsory for first- and ­second-year students at Mount Allison University in 1923, and for women at McMaster University in the early 1920s, a policy administrators at McMaster changed to apply to all first- and second-year students in 1930–31. At Dalhousie University, physical training became compulsory in 1938–39. In 1930, St. Francis Xavier University required an annual physical examination and, in 1936, instituted three hours a week of physical ­education for first- and second-year students. The University of Alberta instituted compulsory training during the Second World War along with a compulsory medical examination for all new students. In 1945–46, the University of British Columbia required all first- and ­second-year students to participate in a physical activity program for two hours each week, though this requirement lasted only a brief time. The University of Manitoba instituted gymnastics and swimming classes for diploma students in agriculture in 1938–39, and, by 1952, required all students entering the university from Grade 11 to take one year of physical education.   2  See, for example, Gidney, A Long Eclipse; McKillop, Matters of Mind; Axelrod, Making a Middle Class.   3  For brief references to the health of the Canadian student body see Axelrod, Making a Middle Class, 111–12; MacLeod, A Bridge Built Halfway, 42. For examples of the growing international literature on the topic, see Prescott, Student Bodies; Lowe, Looking Good; Vernon, “The Health and Welfare of University Students in Britain.”   4  See, for example, Gleason, Normalizing the Ideal; Adams, The Trouble With Normal; Comacchio, The Dominion of Youth, chap. 1. For the United States see Prescott, Student Bodies, chap. 6; May, Homeward Bound, chap. 8.  5 Owram, Born at the Right Time, 135.   6  In this chapter I specifically examine educators’ adoption and use of the terms character and personality as opposed to providing an analysis of the terms as developed and understood by psychologists.   7  See, for example, Howell, Blood, Sweat and Cheers; Bederman, Manliness and Civilization.   8  Smith, “Dampness, Darkness, Dirt, Disease,” 196, 204–5, 211; Comacchio, “The Rising Generation,” 150–2; Gleason, “Race, Class, and Health,” 95–112.

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 9 See Mitchinson, The Nature of their Bodies, 82–7; Vertinsky, The Eternally Wounded Woman, 144; Burke, “Being unlike Man,” 15. 10  Gidney, “The Athletics-Physical Education Dichotomy Revisited,” 134–5. 11 Smith, Sports and Freedom, chap. 14. For Canada, see University of Toronto Archives [hereafter U T A ], Office of the President, A67-0007, box 22, file: Barton, letter, President Falconer to Dr James W. Barton, 3 December 1912; F.H. Harvey, Medical Director of Physical Education, “Gymnasium Report,” McGill University Principal’s Report, 1911–12. 12 Howell, Blood, Sweat and Cheers, 31. For the United States see Dyreson, “Regulating the Body and the Body Politic,” 122, 126, 137; Szasz, “The Stress on ‘Character and Service’ in Progressive America,” 145–7. 13  Mangan, “Discipline in the Dominion,” 149–50; McKillop, “Marching As to War,” 75–93. 14  Atkinson, “Fitness, Feminism and Schooling,” 116; Scraton, Shaping Up to Womanhood, 33; Verbrugge, Active Bodies, 55–6. 15  U T A , B74-0011, University College, box 3-2, Submission from Alumnae Association, University College, n.d.; Report of the University Health Service, Women Students, University of Toronto President’s Report, 1921–22. 16  Gidney, “‘Less Inefficiency, More Milk’,” 298. 17  United Church of Canada / Victoria University Archives [hereafter U C C / V U A ], 90.064v, box 3-20, Report by Guest, n.d. 18 Cassel, The Secret Plague, 123. 19 Prescott, Student Bodies, 93. 20  “Report of the University Health Service, Men Students,” University of Toronto President’s Report, 1921–2; University of Manitoba Archives, UA 20, Box 51-12, Report of Health Inquiry Committee, 11 March 1941. 21  U C C / V U A , 90.064v, box 3-19, Director of Physical Education’s Reports, 1905–13; Hall, The Girl and the Game, 33; Scraton, Shaping Up to Womanhood, 28. 22  U C C / V U A , 90.064v, box 3-19, Report by Scott-Raff, 14 October 1908 and January 1912; and box 1-1, Minutes of the Committee of Management, 15 February 1907; F.H. Harvey, Medical Director, “Report of the Department of Physical Education,” McGill University Principal’s Report, 1912–13. 23 Verbrugge, Active Bodies, 23–4. 24  “Department of Physical and Military Training,” U W O Announcement, 1920–21; Acadia University, Esther Clark Wright Archives [hereafter E C W A ], “Department of Physical Education,” in Acadia University, Report of the President, 1939–40, 21–2.

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25  Kiefer and Pierson, “The War Effort and Women Students at the University of Toronto,” 162. 26  Arthur S. Lamb, “Physical Education,” in Ontario Educational Association, Yearbook and Proceedings (April 1923), 163. 27  E.A. Cartwright, “Athletics and Physical Education for Girls,” Ontario Educational Association, Yearbook and Proceedings (April 1923), 274–81. See also U T A , Department of Graduate Records, A73-0026, box 121/91, “Sports for Girls Develop Citizenship,” Mail, 6 September 1928. 28  Dr Bruce Macdonald, Headmaster St. Andrew’s College, “The Relation of Play to the Education of the Child,” The Public Health Journal 15, no. 8 (August 1924): 343; U A A , Office of the President, RG3, 68-9-280, “Regulations of Corporation Regarding Physical Education,” McGill University, attached to letter from A.S. Lamb, Department of Physical Education, McGill, to Dr Tory, 15 March 1920; Warren Stevens, “Why Athletics?” Health (March 1935): 14. 29  McGill University Archives [hereafter M U A ], R G 42, 2-133, Physical Education Reorganization, Memorandum re Required Programme of Physical Activity for Meeting of Senate, 21 February 1940. 30  Hébert, “Carabines,” 598; U T A , Department of Graduate Records, A73-0026, Box 121/91, “Character Moulded by Capable Teacher,” Globe, 20 October 1923. 31  Hébert, “Carabines,” 609. 32  U T A , Department of Graduate Records, A73-0026, box 121/91, “Woman Doctors Cast Off Halo,” Globe, 22 January 1931; Dr Helen MacMurchy, “The Woman in the Medical Profession,” Acta Victoriana 47, 5 (January 1923), 28. 33  U C C / V U A , 90.064v, box 3-19, Report of Physical Director, March 1911; Cartwright, “Athletics and Physical Education for Girls,” 274–81. 34  Kirk A.W. Wipper, Retrospect and Prospect: A Record of the School of Physical and Health Education, University of Toronto, 1940–1965 (Toronto, 1965), 13; “Health Services,” McGill University Calendar, 1950. 35  Reese, “The Origins of Progressive Education,” 110–15. 36  “PT Situation Explained,” Varsity, 26 October 1921; E C W A , “Department of Physical Education,” in Report of the President, 1939–40, 21–2; “Physical Education,” University of Saskatchewan Calendar, 1955–56; “Physical Health and Recreational Education,” U W O Announcement, 1960–61. In the 1890s the New Zealand government subsidized school swimming programs as markers of good citizenship. See Daley, Leisure and Pleasure, 120. For testing in the United States see Park, “‘Taking Their Measure’ in Play, Games, and Physical Training,” 209–10.

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37  At the University of Western Ontario in 1960–61, both men and women could take aquatics, badminton, tennis, golf, volleyball, soccer, basketball, personal defence, gymnastics, and fitness, among others. Only wrestling was limited to men. See “Physical, Health and Recreation Education,” U W O Announcement, 1960–61. 38  “Report of the Director of the University Health Service,” in Report of the President of u b c , 1942–43, and “Report of the Director of the University Health Service,” in University of Toronto President’s Report, 1947–48. See also McCuaig, The Weariness, the Fever, and the Fret, 106; Prescott, Student Bodies, 107–14. 39  On the rise of psychology see, for example, Nicholson, Inventing Personality; Danziger, Naming the Mind; Cohen, Challenging Orthodoxies; Gleason, Normalizing the Ideal. 40 Armstrong, Political Anatomy of the Body, 22. 41  Mental hygiene was the term applied in the early twentieth century to the work of identifying and preventing mental disturbances or maladjustment and the promotion of mental health. See Prescott, Student Bodies, 8, 118– 19; Cohen, Challenging Orthodoxies, 209. 42  Conrad J. Schwartz, “Report on Health and Psychiatric Services on Canadian Campuses,” Prepared for Canadian Union of Students, January 1967, 29; “Report of the University Health Service (Men),” in University of Toronto President’s Report, 1934–35; “Report of the Director of the University Health Service,” in Report of the President of u b c , 1941–42; “University Physician” in Acadia University’s Report of the President, 1962– 63. For students’ concern about the issue see Canadian Mental Health Association, Canadian Union of Students, and World University Service of Canada, Proceedings of a Conference on Student Mental Health (1963). 43 Gleason, Normalizing the Ideal, 5, 31–38. 44  Dalhousie University Archives, President’s Office, UA3, 39-9, pamphlet, “Communication from the Physical Education Department about Physical Activities at Dalhousie,” 1938–39. 45  Robert Falconer, “The Place of the University in National Life,” University of Toronto Quarterly (1934–35): 4, 3. 46  “Address of Principal,” in McGill University Annual Report, 1935–36. 47  M U A , R G 30, Faculty of Education, 65-175, Minutes of Senate Committee on Physical Education, 5 June 1944. 48  “Report of the Physical Education Department for Men, 1950–54,” Dalhousie University President’s Report, 1950–54. 49  “Report of the Director of Physical Education for Women,” in University of Toronto President’s Report, 1952–53.

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50  Zerada Slack, “Here’s What Physical Education Means to You,” Health (January–February 1957): 18–19, 31. 51  M.L. Vliet, “University Sport during Wartime,” The Gateway (1 December 1942), 4, cited in Lamont, We Can Achieve, 38–9. 52  “Report of the Director of Physical Education for Women,” in University of Toronto President’s Report, 1952–53. 53  This was particularly the case at McGill University and the University of Toronto. See Lathrop, “Elegance and Expression, Sweat and Strength,” 240; M U A , RG 42, 1-22, E.H. Cartwright to Dr Lamb, 13 April 1921. For the United States see Verbrugge, Active Bodies, 6–7. 54  Historians have shown that psychologists played a particularly prominent role in reinforcing traditional gender roles and blaming mothers for their children’s perceived psychological disorders. See, for example, Gleason, Normalizing the Ideal; Adams, The Trouble With Normal; Buhle, Feminism and Its Discontents, chap. 4. 55 Gidney, A Long Eclipse, chap. 7. For more on the contradictory nature of women’s place on campus see Hébert, “Carabines.” 56  See, for example, Susman, “‘Personality’ and the Making of TwentiethCentury Culture,” 212–26; Lears, “From Salvation to Self-Realization,” 3–38; Szasz, “The Stress on ‘Character and Service’ in Progressive America,” 145–56. 57  Pierre Dansereau, “Introductory Remarks,” in Canadian Mental Health Association et al., Proceedings of a Conference on Student Mental Health (1963), 3.

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Section Two

Defining and Contesting Illness

This section addresses the power of physicians to determine what bodily conditions are significant enough to attract medical interest and how to treat those conditions. Making these determinations has not always been straightforward because medical specialties have been in competition with each other, differing theories of causation have come out of those specialties, and perspectives have been contingent on who the “experts” were and who the patients were perceived to be. Certainly, specific diseases resonate with practitioners because of their challenge to the values of society. An in-depth study of late nineteenthcentury and early twentieth-century Austrian, Swiss, and German ­medical texts on osteomalacia, a bone disorder, reveals the way male experts made women the testing ground for their theories of disease causation. An analysis of the treatment of male infertility in Germany the 1950s and 1960s examines how competing specialties sought solutions to a problem seen to strike at the heart of masculinity. In both chapters, the authors provide insight into the ways in which medical authority is contested within medicine through definitions, diagnosis, and treatment. The next two chapters focus on people who would not normally be medical or health power holders or brokers, but who add to the complexity of health seen through the perspective of various specialties: patients and health activists. Parents who contested expertise about the meanings of disability for their children are the subject of a study based on mid-twentieth-century New Zealand. Looking at mental disability raises the query of whether disability is a health issue. Can you be disabled and still be healthy? Both states are contingent in meaning and so the answer to that question would be dependent on time and

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place. Children needed someone to challenge medical expertise for them and parents took on this role in a variety of ways. Advocacy was also central in overturning the perception of H I V /A I D S as a male ­issue in Ontario, Canada, in the 1980s. Through activist groups, women worked to shift public and policy perspectives to take account of the particular issues for women with H I V /A I D S . Rather than describing an internal medical debate about disability and H I V /A I D S , both chapters highlight a more public debate that occurred as lay people took it upon themselves to contest definitions that limited the potential for assistance to those in need. Crises seem to make room for alternative thinking and alternative resistance. Taken together, these four studies throw into relief the way society and medicine are connected, the significance of time and place, and the ways in which illness is read through gender. They raise questions about who has authority to determine who is healthy and who is not. For those not healthy, who provides treatment? Who provides care? And who decides what kind of treatment or care?

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5 Osteomalacia: Femininity and the “Softening of Bones” in Central European Medicine (1830–1920) Brigitte Fuchs In 1913 the Dutch physician W. von der Scheer summarized more than half a century of research published in German on the porotic (porous) softening of bones in adults, which after 1860 was intensely discussed as a female disorder of unknown cause. In his words, “[t]oday, the notion of osteomalacia signifies a clinically as well as a pathologically-­ anatomically well-defined chronic disorder occurring usually among females in pregnancy or in the puerperium which is found in certain regions endemically.”1 The present-day etiology of osteomalacia (and rickets) as a generalized condition of defective bone mineralization resulting from a deficiency (or resistance to the action) of vitamin D, a deficiency of phosphate resulting from renal losses, or a lack of dietary calcium was discovered as late as the 1920s and 1930s. The causation of porotic bones by unfavourable “environmental” conditions such as a cold, humid climate and poor living conditions (malnutrition, undernutrition), however, had been part of the medical knowledge since Francis Glisson’s (1597?–1677) treatise on rickets published in 1671.2 In the seventeenth and eighteenth centuries, some physicians had observed cases of “adult rickets,” “mollities ossium” (abnormal softening) or “osteomalacia” (malacosteon), but women’s greater susceptibility to the disorder was only noted by the early nineteenth century.3 Against a background of deteriorating living conditions during pro­toindustrialization and early industrialization, a disease that today would be diagnosed either – and more probably – as osteoporosis (brittle bones) or osteomalacia (softened bones) was not restricted to elderly

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people but occasionally affected women in their thirties and early forties, most of whom had borne several children. Moreover, in women of procreative age the condition did not remain restricted to severe pains in the costal (rib) and sacral regions as was observed in contemporary male cases, but rather produced demineralization of the bones to a  point that a deformed and “contracted” pelvis that sometimes ­fractured made childbirth a deadly risk. The disorder was depicted as ­being exacerbated by repeated pregnancies, births, and breastfeeding of infants, and was said to be accompanied by a progressive softening and deforming of the pelvis and the bones in general, forensically visible in the severely deformed femurs, and a loss of body length up to 20 centimetres or more.4 Osteomalacic women were forced to stay in bed, a treatment followed in some cases for “osteomalacic cachexia” (wasting syndrome), leading to death within six to ten years. In Central Europe around 1860, this advanced form of osteomalacia was called puerperal osteomalacia and as such was defined as a female disorder and identified as the proper form of the “disease.” The historically specific context of constructing osteomalacia as a female disorder will be examined using medical sources published ­ in German from Austria, Switzerland, and Germany in the nineteenth and early twentieth centuries. So-called puerperal osteomalacia was considered to be rooted in the “female system.” In the Enlightenment, the ­ female organism had been separated from the male / universal “l’homme machine” by indicating the greater fragility of the female skeleton, thus homogenizing the ancient regime’s social differences into gendered (and racialized) categories. The comparative broadness of the pelvis was considered to facilitate the female duty to bear children, thus inscribing gender difference into the bones. The first argument of this chapter is that osteomalacia, as a lethal weakness of the pelvis preventing “natural” childbirth, came to represent the nature of female illness, thus providing a framework for medical misogynist ideas – such as the idea of the pathological character of femininity – prevailing in fin-de-siècle Central Europe. At the same time, osteomalacia also addressed the need for contraception with respect to the threat of puerperal osteomalacia. The latter after 1872 was theorized as the ­result of “hyperactive ovaries” that had to be treated with oophorectomy (so-called female castration).5 The second argument is that osteomalacia discourse is essentially linked to the medicalization of the female body, legitimizing the need for – at that point experimental – gynecological surgery and modern gynecology to control the female

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procreative “system.” The significance of this study lies in the legacy of the historic osteomalacia in more recent osteoporosis discourse.6 The origins of that legacy began with the discrepancy of the rare occurrence of pelvic osteomalacia (osteoporosis) and its importance for medical discourse.

The Rare Occurrence of Puerperal Osteomalacia and Osteomalacia Discourse Happy deliveries come quickly after one another, and time dissipates all ­concerns and the anxiety … normally accompanying the moment of giving birth. All of a sudden, however, conditions become dreadful and menacing; searing pains pervade the body, pains buried deep in the womb: the deli­ cate physique is undermined, the body visibly distorted, the tall stature ­decays to crippledom, the legs give out, chaining the desperate victim to ­painful bed rest, the deliveries becoming visibly more troublesome and ­dangerous until they cannot be accomplished, and art must deploy its most bloody means in order to restrict the unfortunate’s wretched life. Sufferings after sufferings, torments after torments, and while the once well-built body decays to an amorphous mass of flesh, the use of the senses is lost, sight is lost, all bodily functions happen unconsciously, only the capacity to become a mother is neither undermined nor disturbed. Once more, a new life ger­ minates in these tremendous devastations, and the same means which open the gate to life for a child conduct the mother into dissolution, into a better life there.7

With such a gothic-like description, the German pioneer of gynecological surgery, a professor of obstetrics at Bonn University, Hermann Friedrich Kilian (1800−1863) in 1829 introduced a new lethal “disease” that he called osteomalacia universalis feminarum.8 His study, the first ever written on osteomalacia, depicted the disorder as a mysterious suffering of flourishing mothers, beginning with pains in the spine and in the pelvis; after some years they lost the capacity to walk, at first moving laboriously with the aid of two walking sticks and eventually becoming bedridden.9 Kilian’s pathology colourfully depicted a terrifying, gradual physical decline and included as potential causes some impression of horror or permanent concern for daily nutrition,10 thus implying it was not caused by an actual lack of adequate nutrition. Though he conveyed the impression that osteomalacia occurred frequently, his conclusions were based on no more than eleven cases from British, French,

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and German sources on malacic (softening) and fracturing bones published in the previous eighty years, complemented with some specimens of malacic pelvises.11 Though fracturing bones in old people of both sexes had been observed more frequently, he maintained that “male cases” never showed the same degree of general bone corrosion as did female cases.12 Kilian concluded that “genuine osteomalacia” was exclusively a female disorder, cordoning off his new disease with the suggestion that it was not permissible to confuse softened (fracturing) with fracturing brittle bones. He considered Anne-Elisabeth Queriot, “femme Supiot,” a Parisian who had died in 1752, as the most characteristic case of “genuine osteomalacia.” She had been subject to autopsy by her physician, Morand, who described her bones as being softened to the point that she could use her feet as a cushion. Morand denied the syphilitic or rachitic origin of her suffering, considering it some kind of nutritional disorder similar to scurvy.13 While it might well be that “Mme Supiot’s” malacia was caused by some kind of malabsorption, most case descriptions in the eighteenth and early nineteenth centuries dealt with women on whom gynecological surgery had to be performed because their pelvis had proved to be too softened to deliver in a “natural way.” The first cumulative – later defined as endemic − occurrence of osteomalacia was reported in East Flanders in Belgium. Between 1828 and 1840, Dr M. Hoebeke, a community physician employed in Zottegem, had performed Caesarean sections on ten women of his district. Hoebeke remarked that his patients quite obviously suffered from rickets, which, as he remarked, “also occurred in adults.”14 However, he considered “progressed” osteomalacia to be a consequence of the usage of large quantities of “whale oil,” with which local women wished to cure their presumed rheumatic sacroiliac pains. Professional observers of Hoebeke’s operations, who were predominantly members of the surgical societies of Gent and Brussels, rejected Hoebeke’s conclusion that the patients were suffering from adult rickets. They rather suggested that the phenomenon occurred in spite of the intake of cod liver oil, a medication that had been recommended by German and Belgian governmental commissions concerned with combatting rickets in children.15 They noted that all the patients were obviously women “from the low ranks of society” and suggested alternative causes such as the poverty of the rural population, malnutrition, the wet soil and climate, and the fact that the malacic women spent most of their time indoors bent over a spinning wheel producing Brussels lace.

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From that point on, locally cumulated cases of “puerperal osteoma­ lacia” were observed regularly, the number of cases ranging between ten and fifty.16 A report by the Japanese gynecologist Masakiyu Ogata (1915) of its occurrence in a district neighbouring Tokyo suggests a clear correlation between softened bones in women and the conditions of proto-industrialization because none of the cases had occurred before the rising prices and taxes at the turn of the century had forced the people of the region to change their diet from rice and barley to batata (sweet potato).17 While European reports on the “puerperal” bone softening are never similarly detailed with regard to dietary conditions, they suggest with respect to their regional foci a correlation between the occurrence of “female osteomalacia” and the deteriorating social ­ ­conditions of rural populations in proto-industrialized areas. In the 1850s, 1860s, and 1870s, endemic osteomalacia was observed predominantly in Germany, particularly in the broader surroundings of the ­ascendant Westphalian mining industries,18 and in northern Italy.19 Endemic o ­ steomalacia was reported later in Switzerland,20 southern Italy, s­outhern Germany,21 and the Austro-Hungarian Empire and Japan.22 However, the Austro-Hungarian endemic cases affected not only women in proto-industrialized areas in Bohemia and Moravia23 but also women in rural areas in Bosnia, Croatia, Slovakia, and Galicia (Poland) who suffered from serious starvation.24 In 1914 the total number of cases of advanced puerperal osteomalacia, be they singular or endemic, that had been described since 1750 all over Europe did not exceed about 400. Nevertheless, after 1870 “female osteomalacia” became the only bone disease that was discussed intensely in medical and particularly gynecological journals. Premature male cases of malacia (porosis) were reported, though it was taken for granted that the cause of these cases was different from that of female osteomalacia as much as it was taken for granted that old-age osteoporosis (malacia) and rickets had a different cause.25 The presumed evidence that malacia was a different disorder from rickets in children was the medical finding that rickets, but not osteomalacia, caused a softening of the skull. After the First World War, however, an “epidemic” of osteomalacia that occurred in Vienna was described as affecting firstly the cranium, then the jaws, and ultimately the whole body, particularly of elderly women, and it was considered an obvious effect of starvation.26 By that time, it was taken for granted that osteomalacia was some kind of rachitic and social disorder that could not be classified as endemic. The cause of porosis and malacia in patients of different ages and genders encouraged the study

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of porotic bone diseases in general and the separation of porotic from other bone diseases specifically. A series of detailed case descriptions indicated that some patients presumed to have osteomalacia may in fact have suffered from other bone diseases, such as osteogenesis imperfecta or Morbus Paget (osteodystrophia deformans).27 It is still in question how far the discovery of osteomalacia cases in the previous years was dependent on the area-wide implementation of modern public health institutions, a higher density of physicians per capita, and the eagerness of many Central European physicians to diagnose “puerperal osteomalacia” because of its relative importance in medical discourse. Certainly, the outstanding medical interest in osteomalacia was rooted in the suggestion that osteomalacia occurred as a consequence of female (over-)procreativity and in the idea that the clarification of the nature of the disease would ultimately reveal the still-mysterious “function of the female system.”

Embodied Female Weakness It seems that what Dr Morand had signified in 1752 as the “singular” case of Mme Supiot was in the 1840s notorious even among a non-­ expert middle-class public all over Europe. The general public interest aroused by her case reflects the eminent importance of her case for the medical theorizing on gender and bones after 1800. Enlightenment discourse had legitimated the civil and political discrimination of women to their physical weakness, visible and measurable (for the expert) in the greater fragility of the “female skeleton.”28 The program of separated spheres – men’s usefulness for the state consisting of producing goods and women’s of bearing children – was founded in human anatomy. The comparative anatomical broadness of the (white) female pelvis provided the proof that women’s exclusive purpose was to reproduce. The female “natural” reproductivity and the “female system” circumscribed female health, while “health” in general circumscribed the “male” capacity to work, as both Reeve and Levine-Clark have argued in this volume (see chapters 1 and 2). In the eighteenth century, the extraordinary case of “femme Supiot” as a woman whose bones progressively softened during pregnancies ending in miscarriage or stillbirth was cited frequently to reveal that the very nature of women was weakness. Mme Supiot embodied female weakness expressing itself in softened bones, since osteomalacia at the time was not viewed as depending on female reproductivity in any

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specific way. Kilian, on the other hand, constructed a female disorder that killed women through their reproductive sexuality, suggesting that cases of osteomalacia in women who had not borne children were due to their “exaggerated” sexual activity, to syphilis, or to the use of “abortive means.”29 He stated, however, that osteomalacia was naturally cured in cases when already diseased women did not become pregnant again, though their menstruation might be accompanied by the characteristic malacic pains.30 Kilian’s conceptualization of the female body was one that the US anthropologist Emily Martin found expressed in American women’s views of reproductive processes in the 1980s.31 Martin’s study reveals that most women interviewed described their body as a machine, the industrial metaphor reflecting professional discourses that have constructed the female body as a reproductive machine designed to produce children. Menstruation, however, was seen in negative terms, as a sign of failure to reproduce. In Kilian’s time Western medical discourse constructed pregnancy as women’s “normal state.” Consequently, in 1829 he could both describe the presumed entropic lethal decay of individual women who, he assured his audience, were normal, and at the same time indicate strongly that the female self-destructive force was due to “over-production.” Kilian’s view of the female “body machine” was specifically due to the medical reassessment of the role of women in procreation in the eighteenth century. Pre-modern medical discourse assumed that children were the product of a mixture of uterine blood and semen, the latter in Aristotelian tradition being considered more significant for procreation because of “forming” the child, the female blood figuring as passive “material” that must be formed.32 In the late eighteenth century, this narrative was challenged by medical scholars who were convinced that the “female testes” or ovaries were at least of equal significance for ­procreation as the male ones and that women’s contribution to producing children was more important than men’s. “Ovarism” constructed women with respect to procreation as productive, also reflecting the Enlightenment belief that women existed exclusively for bearing children. The ovarist discourse corresponded to new governmental concerns to increase national populations and reduce infant mortality through hygienic improvements. For example, a 1794 law in Prussia stipulated that women must breastfeed their infants, since the rearing of children with artificial food was becoming common even among many rural populations in Central Europe.33 State intervention to

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produce better mothers was paralleled by sentimental middle-class discourses about motherhood’s achievements. The family’s mother was represented as the centre of a now-separated domestic sphere;34 she became depicted as the “natural” teacher of her children, thus informing emerging early maternalist thought that claimed education and civil rights for women as mothers.35 The ovarist theory became more widely accepted in the 1840s, when the French physician Achille Chéreau (1817−1885) in 1844 stated that women were women because of their ovaries (productive gonads), while the uterus was of a secondary, merely reproductive importance.36 Among the most ardent protagonists of “ovarism” was the founder of physiology, the German anatomist and anthropologist Rudolf Virchow (1821–1902), who remarked on the function of the ovaries: “Remove the ovary, and we shall have before us a masculine woman, an ugly halfform … the heavy bone formation, the moustache, the rough voice, the flat chest, the sour and egoistic mentality and the distorted outlook … in short, all that we admire in woman as womanly is merely dependent on her ovaries.”37 The shift to the idea that the master organ of the female system was the ovary not the uterus was in part based on speculations about the impact of the gonads on the presumably differentiated process of skeletal growth in men and women. Any impact of the testes on the male skeleton (growth) was denied, the argument being that the skeletal development of males who had had their testes removed before the age of puberty (e.g., to remain a boy soprano) did not deviate in skeletal growth from the males who had not. Female castrates, on the other hand, were not available and it was taken for granted that the more “delicate” female bone formation must be an effect of the female gonads; therefore, the female body was defined as essentially sexual.38 Thomas Laqueur demonstrates in Solitary Sex: A Cultural History of Masturbation (2003) that the eighteenth-century discourse on masturbation as a “vice” that was as noxious for men as for women – its consequence being blindness, softened bones, and softened brains – meant the promotion of a “democratic sexuality” by inscribing the capitalist mode of production into the body.39 He considers masturbation among the most important Enlightenment subjects but overlooks the restriction of this “democratic sexuality” to Protestant countries.40 A more common “sexual democratization” in both Protestant and Catholic countries seems to be the ovarist belief that women became at least as sexually exhausted as men because of their “productive” gonads. And, as argued, this ovarist perspective appears enhanced through Kilian’s

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conceptualization of female osteomalacia. He emphasizes that the “secondary” uterine reproductivity in malacic women remained intact (“healthy”), even though such women were dying of exhaustion that was characterized as sexual not least by the symptoms of bone softening and loss of sight. He was the only expert ever to observe the latter symptom, which was among the most characteristic consequences of (male) sexual “vice.” It might be said that Kilian’s approach was to locate the popular medical imagination of (male) sexual decay caused by (masturbatory) “waste of semen” in healthy women whom he depicted as having produced too many children. The way Kilian described the female body was as an individual “female machine” with a presumed excess of sexual (procreative) power bringing about the overproduction of children, with the possible effect of the complete physical destruction of the functioning “machine.” In the terms of classic economics, the female body was represented as ­incorporating both a structural crisis and an irrational breakdown of the whole “system.” In medical terms, femininity as such was viewed as a pathological state. The more common popular and medical imagination of femininity as permanent illness was represented in female hysteria. Hysteria and osteomalacia discourse overlap with respect to the ideas of a possible ovarian causation and a femininity that was essentially irrational. However, the physical symptoms of hysteria (e.g., hysterical paralysis) were considered a “lie”; osteomalacia, on the other hand, was considered a true lethal disorder, exposing women’s very (system) failure.41 The definition of femininity as a disorder was accompanied by putting forward a need for medical supervision of women of all classes by a new class of male obstetrician-surgeons or gynecologists.

T h e M o n s t r o u s P e lv i s : O s t e o m a l ac i a , P e l v i m e t r y, a n d t h e M a k i n g o f a Gynecological Field The exception to the nineteenth- and early-twentieth-century medical rule not to perform Caesarean sections on living delivering women was provided by osteomalacia patients. Indeed, in the 1830s and 1840s, the  development of gynecological surgery was based at first on the ­osteomalacia discourse. For example, in Belgium between 1828 and 1843 Dr Hoebeke performed thirteen “gastro-hysterotomies” indicated by “rachitic” pelvises.42 In deliveries with a hopeless prognosis the common proceeding was to crush the fetus’ body (particularly its skull) in

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the womb and to remove its fragmented remains.43 However, contemporary obstetricians remarked that on malacic patients the procedure could not be performed because of the extreme degree of the pelvis’ “contraction,” thus making a Caesarean section inevitable.44 Since half of Dr Hoebeke’s patients survived the procedure, medical observers raised the question of whether the performance of Caesarean sections, despite the high mortality of the women operated on, was ethically more correct than the “murder of an innocent infant just to save the selfish mother.”45 The suggestion that a Caesarean section should be considered a serious alternative to the fragmentation of a fetus in the womb was also advocated by Kilian. Indicating Dr Hoebeke’s successes, he stated in his handbook of gynecological surgery published in 1840 that the most important indication for performing a section was an ­osteomalacic and severely rachitic pelvis.46 Despite the need to perform a Caesarean section on women whose pelvises were osteomalacic or severely rachitic, Kilian maintained the separation of female general osteomalacia from rickets (in children) largely on the basis of his attempt to construct female osteomalacia as a disorder requiring surgical intervention. However, the theory that osteomalacia was just adult rickets was substantiated by forensic evidence showing that all kinds of softened bones in both sexes and all ages and of fracturing bones (mostly in elderly people and women who had borne several children) were porotic. The French scholars Armand Trousseau (1801–1867) and Ernest-Charles Lasègue (1816–1883) had identified rickets in both children and adults as a form of osteoporosis in 1849.47 However, their findings were criticized by Virchow, who in 1853 rejected the idea that rickets was a porosis.48 He distinguished rickets from osteomalacia, which he asserted was “actually osteoporosis.”49 Explaining that with rickets the mineralization of children’s bones did not occur, whereas osteomalacia involved a demineralization of already mineralized bones, he insisted that rickets and osteomalacia must be strictly differentiated.50 As a consequence, the separation of rickets and osteomalacia became a doctrine in Central European medicine.51 In 1857, Kilian relied on Virchow’s findings to substantiate his concept of “osteomalacia universalis feminarum” as a female disorder that he wished to call “halisteresis” (lime salt deficiency in the bones) to emphasize the softened character of the (pelvic) bones.52 But his suggestion to differentiate strictly between softened and brittle bones was not accepted because at that point the notion of “puerperal osteomalacia” for both phenomena was coming into use, the latter introduced by

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Carl Conrad Theodor Litzmann’s standard work on pelvimetry, Die Formen des Beckens, first published in 1861.53 Litzmann (1814–1890) gave the precise dimensions of the “normal” pelvis and specifications about the pathology of small pelvises, the latter presumably seen as a risk to deliveries. The absolute dysfunctional form was seen to be either the deformed osteomalacic or the (deformed) rachitic pelvis. Litzmann based his research on specimens that were kept in different anatomical and gynecological collections. In Die Formen des Beckens, he included an appendix on the existing knowledge of osteomalacia that was based on 131 cases that had occurred all over Europe since the early eighteenth century. Litzmann stated that of these 131 cases, 120 were women and some eighty-five (i.e., sixty-five per cent) demonstrated that osteomalacia was “most common among women of procreative age.”54 The presumed female character of osteomalacia was once more established by the statistical fact that most published cases of a softened pelvis related to women in contexts involving pregnancy and delivery. Litzmann listed no more than eleven cases of softened pelvises in men, considering them with non-puerperal female cases to be “rheumatic,” “senile,” “syphilitic,” or “neurotic.”55 As a rule, experts expressly omitted male osteomalacia cases from their investigations because male cases could obviously not be “puerperal.”56 Even after autopsy findings had proved that a strict distinction between porotic (malacic) diseases ­affecting the pelvis (puerperal osteomalacia) and those affecting the ­thorax and spine of elderly people (senile osteomalacia) was impossible, and though male cases were more frequently observed after 1900, no doubt was cast on the female character of osteomalacia. The construction of osteomalacia as a female disorder was very much related to the emergence of the gynecological expertise of pelvimetry, which served primarily to assess the female pelvis in relation to delivery. The premise was that only a “normal” pelvis was adequate for a “normal” (vaginal) delivery, which presumably was performed by a midwife. Pelvises that were deemed too small were considered to be beyond the expertise of the latter, even though, as was admitted by academically trained obstetricians, a small pelvis did not necessarily lead to complications during deliveries.57 Against a background of modernizing states establishing systems of public health and hygiene, the professionalization of academic medicine and subdisciplines such as gynecology, and the legal regulation of “traditional” midwifery and its subordination to academic medicine, academically trained male obstetrician-surgeons

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initially claimed the field of pathological pelvises.58 Definition of that field was based on clinical statistics that demonstrated the relatively high rates of small pelvises; for example, Litzmann cited 13.1 per cent for his maternity clinic in Kiel in 186159 and Franz von Winckel cited 5 per cent or more for his clinic in Dresden in 1882.60 Litzmann, a fervent advocate of pelvimetry, was considered to have provided an important starting point to establish gynecology and obstetrics as a medical specialization. In 1873, “in continuation of Litzmann’s monograph,” the German gynecologist Carl Hennig (1825–1911) added 155 cases of osteomalacia that it had not considered.61 He also described deformities of the osteomalacic pelvis that had been observed more recently and reported on the results of the Caesarean sections performed. Hennig’s article was published in the German journal Archives of Gynaecology, its main focus being gynecological surgery and pelvimetry, with osteomalacia constituting a regular topic. Franz von Winckel (1837–1911), co-editor of the journal and president of the German Gynaecological Society, founded in 1885, was also a strong proponent of pelvimetry. He was the author of the influential Textbook of Obstetrics (1893), which contained a systematic classification of pathological pelvises. He essentially adopted Litzmann’s nomenclature, adding pathological forms that had been described more recently.62 While Winckel did not challenge the theory of the ovarian causation of osteomalacia that had become a doctrine during the 1880s, he did agree with Litzmann’s thesis that osteomalacia was a female disorder that developed predominantly under unfavourable environmental and social conditions. Both Litzmann and Winckel exhibited some concern for women’s health by describing the physical deterioration, to the point of death, of women who had to work and to bear, suckle, and raise numerous children at the same time.63 Concern about the impact of hard work on women’s health coincided with the contemporaneous middle-class discourse on “national womanhood” that emphasized the political importance to the state of dutiful “national mothers,”64 as exemplified in the writings of the anti-clerical French “prophet-historian” Jules Michelet (1798–1874). Michelet assumed a basic antagonism between the female body and industrial ­labour, productive work being seen to undermine (working class) women’s health per se. In addition, the health of female labourers was eroded by sexual exploitation and syphilitic infection by “ruthless” men of their class. For the sake of women’s health, Michelet concluded, the middle-class breadwinner / housewife model must be extended to the

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French working class, the Republic benefiting from the civilizing effect exerted by housewives on husbands, who were to be subordinate to their wives “at home.”65 Moreover, Michelet was the author of the influential romantic reinterpretation of the popular figure of the “witch.” In his book La sorcière (1862), he depicted witches as popular female healers and practitioners of female health who knew the arts of contraception and abortion for which they had been persecuted by the Roman Catholic Church.66 Michelet’s discrete advocacy for birth control and women’s sexual rights, combined with his reconfigured conception of marriage as a republican institution that was to protect women’s health, informed nineteenth-century liberal maternalism and moderate feminism up to the interwar years. However, despite his rejection of Roman Catholic misogyny, Michelet exhibited a basic ambivalence vis-à-vis femininity. As pointed out by Ludmilla Jordanova (1989), Michelet depicted women – and women’s bodies – as indefinitely weak and characterized by permanent disorders such as “female emotionality,” “love,” and “fanaticism,” which he located in the uterus. Femininity was aligned with decay, death, and irrationality,67 an idea also prevailing in the medical discourses on hysteria and osteomalacia. After 1870 the medical discourses included an ovarian causation and a surgical treatment (oophorectomy – excision of ovaries) for both disorders.

T h e T h e o ry o f O va r i a n C au s at i o n of Osteomalacia and its Cure b y M a s c u l i n i z at i o n A close link has been noted between occurrences of osteomalacia and the development of gynecological surgery in Central Europe. Jutta Blönninger (1980) focused in her doctoral thesis on oophorectomy, a procedure that was performed on osteomalacic women particularly between 1887 and 1906.68 It used to be called female castration (weibliche Kastration), indicating the excision of both ovaries (gonads) without removing the uterus. Chandak Sengoopta (2000) deals with osteomalacia in an article on the pioneering role played by German gynecologists in the endocrinological redefinition of femininity, which in the first decade of the twentieth century was associated with the ovaries rather than the uterus.69 Sengoopta considers osteomalacia the key to this shift on the grounds that its cause was deemed to be a hyperfunction of the ovaries, thus giving way to a conceptualized endocrinology, though, as he states, a real understanding of endocrinology was still missing.70

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In the nineteenth century, however, osteomalacia’s significance was seen in its occurrence as a disorder of the skeletal master system that a priori was gendered (and racialized). When the female skeleton was described as being more delicate than the male one, its different for­ mation was linked in some way to the ovaries, which after 1848 were considered the master organs of the “female organism.” The crucial question of the relationship between the ovaries and the uterus was associated with the question of skeletal sex differentiation via the unproven assumption that female castrates (women who had had both the uterus and ovaries excised) were “half male.”71 Even so, gynecologists observed that the menses continued frequently after ovariotomies, concluding that there was no relation between the uterus and the ovaries.72 Clearly, more studies were needed. As a consequence of “endemic osteomalacia” in northern Italy, in 1876 in Pavia, Edoardo Porro (1842–1902) introduced a modified Caesarean section that included the removal of the uterus and the ­ovaries. His supravaginal amputatio utero-ovarica was considered to be indicated for women with a deformed osteomalacic or rachitic pelvis, for whom a Caesarean section was presumed to be inevitable anyway. Castration would prevent further pregnancies and therefore further Caesarean sections and the exacerbation of malacic suffering.73 Many gynecologists had observed a quick postoperative improvement in non-pregnant osteomalacia patients, such as their regaining mobility.74 This conclusion was first noted by the German gynecologist Hermann Fehling (1847–1925), supported mainly by his own study of the effects of Porro’s operation on osteomalacia patients. Of forty-four women operated upon, eighteen had died but twenty-six had recovered fully as a consequence.75 Fehling therefore concluded that osteomalacia had to be regarded as the most important indication for oophorectomy, in contrast to the hysteria that had informed the development of the procedure by the German gynecologist and eugenist Alfred Hegar (1830–1914).76 In January 1887, Fehling operated on a non-pregnant osteomalacia patient, reporting that the operation had been a success. The patient, who had been bedridden after the birth of her fourth child, became mobile again and was able to take up her work as a washerwoman.77 Consequently, female castration came to be performed widely on osteomalacic women, malacia being considered the most legitimate indi­ cation for the procedure.78 From 1887 to 1906, it was performed on more than 200 malacic women in Germany, Switzerland, Italy, Austria, Hungary, and Russia.79

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Initially, Fehling and other gynecologists performing oophorectomy showed little interest in explaining why it worked. In the 1890s, Fehling suggested that osteomalacia was caused by a “morbid hyper-function of the ovary,” which produced reflex venous hyperemia (increased blood flow to a body part) by stimulating the sympathetic nerves. He believed that the hyperemia affected the skeleton by inducing the demineralization of bones and that oophorectomy exerted its therapeutic effect by removing the pathological widening of blood vessels (vasodilatation) caused by hyperactive ovaries. The notion of hyperactive ovaries was based on Fehling’s observation that osteomalacia patients were remarkably fertile.80 Fehling considered the connection between the “activity of the ovaries” and osteomalacia to be further supported by the observation that the malacic suffering increased during menstruation and ­decreased after the operation, and by the fact that osteomalacia did not occur in young females before menarche.81 In other words, Fehling and other contemporary gynecologists constructed osteomalacia as an effect of degenerated ovaries that were identified with a presumed physio­ logical (morbid) hyper-femininity that expressed itself in a softening of  bones that could be cured by masculinizing osteomalacic women. Fehling, and other contemporary gynecologists, saw “castration” as an efficient method of suppressing menstruation.82 At that time menstruation was regarded as the essence of femininity and proof of female inferiority vis-à-vis men, essentially a female failure to control a bodily or sexual (reproductive) function. The osteomalacia discourse, however, tended to describe the female body as a productive one, identifying the disease as the effect of sexual overproduction owing to “hyperactive ovaries.” Consequently, it defined women’s health mainly in terms of their capacity to work, with therapies aimed at restoring their mobility. While initially the osteomalacia discourse had coincided with liberal maternalism indicating women who were physically exhausted by their double burden, from the 1880s to the 1930s it operated predominantly as a discourse on “rational reproduction,” birth control depicted as a sine qua non of women’s health. It dealt to a large extent with the “decoding” of the female reproductive function and surgical techniques to control female fertility. The female body and its (reproductive) sexuality remained associated with irrationality, modern medicine presenting itself as striving for control over female sexuality. For example, the renowned German gynecologist and osteomalacia expert Ferdinand Adolf Kehrer (1837–1914) suggested that castration or sterilization might be a means to eugenic ends,83

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driving home the message that control of female sexuality was not meant necessarily to serve women’s contraceptive needs or reproductive rights. Osteomalacia discourse promoted the triumph of modern surgical technique over the female body. The claim for birth control as a civil right, made predominantly by medical professionals from 1860 to the 1890s in the German Empire, was based on the argument that women who were forced to bear too many children eventually wore down. However, they did not hold the “female system” liable, but rather male sexual privilege. The most prominent German pioneer of birth control, Wilhelm P.J. Mensinga (the pseudonym of the German physician C. Haase), the “inventor” of the Mensinga diaphragm, wished to charge the husbands of women dying during the delivery of their tenth or subsequent child with (sexually motivated) murder.84 From the outset, osteomalacia discourse depicted the lethally softened bones of diseased women as the consequence of individual high birth rates. Any relation of osteomalacia to nervous disorders such as hysteria was rejected, though mid-nineteenth-century medical discourse had presumed a possible nervous causation for rachitic diseases. In 1895, a study revealed that “malacic paralysis” was not nervous but rather a product of the weakness of the musculoskeletal system.85 ­ Similarly, an occasionally presumed etiological context of puerperal osteomalacia with mental disturbances such as (old age) dementia and psychosis could not be proved.86 Osteomalacia discourse, then, remained at odds with the hegemonic bio-political discourses of the imperialist era. A ­nationalistic and militaristic rhetoric, particularly in the German Empire, promoted a considerable increase in national birth rates, depicting the decrease in (marital) natality as a consequence of social or “racial” degeneration. The degeneration was associated with “racial ­hybridization,” male effeminacy (male hysteria, neurasthenia), and the masculinization of women (feminism). It was anchored in (hereditary) syphilis and particularly in militaristic rhetoric circumscribed with the metaphor of “rotten bones.” In contrast, German osteomalacia experts described the – female connoted – disease of “rotten bones” as an inevitable consequence of individual women’s high birth rates. Osteomalacia, therefore, indicated the medical inevitability of birth control. Not all professionals, however, were convinced that osteomalacia was caused by hyperactive ovaries, rather pursuing the idea that it was a female metabolic disorder or, less prominently, the correct idea that it was a porotic disorder that was not exclusive to women.

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A lt e r n at i v e C au s e s a n d T r e at m e n t s After 1890, the ovarian causation was considered by many to be proved by the fact that the operative removal of the ovaries improved the general condition of patients, with medical journals reporting on the operations. Nevertheless, the theory continued to be debated, though most Central European osteomalacia experts presumed at least a partly “sexual” cause. The most influential example of such an approach considering a combination of sexual, environmental, and social factors is the study of the Swiss surgeon Ludwig Gelpke (1854–1946).87 It was based on numerous cases of osteomalacia in the valley of Ergolz in the Canton of Basel and in southern Alsace and it contained a statistical survey on endemic osteomalacia worldwide. In 1891, Gelpke suggested that endemic osteomalacia prevailed particularly in zones of Pleistocene fold mountains such as the Alps and the Apennines.88 He indicated “three causal moments”: “sexual” (sexual reproduction), “hygienic” (poverty, malnutrition, lack of sun), and “territorial” (endemic occurrence).89 Supported by a study of endemic osteomalacia in cattle that could be cured by feeding them with calcium or phosphate,90 Gelpke pointed out that, theoretically, the consumption of eggs, cheese, and milk would prevent the occurrence of the disease.91 While he emphasized that osteomalacia was by no means exclusively due to poverty, he saw further support for the ancient environmental theory in the fact that cases of endemic puerperal osteomalacia in Germany and Belgium had ceased to occur “probably due to improved living conditions (consumption of meat).”92 However, a correlation between poverty and the occurrence of pelvic osteomalacia was not totally convincing. In Central Europe endemic ­osteomalacia did not occur in all populations with low standards of ­living, just regionally. Gelpke himself pointed out the fact that because of their home industries his patients in the valley of Ergolz were in no way among the most undernourished Swiss populations. As a result, the doctrine of the ovarian (“sexual”) causation of osteomalacia was not easy to refute especially when some endocrinological experimentation with the castration of cattle and female dogs demonstrated the influence of an “inner secretion” of the gonads on bone formation, suggesting that osteomalacia could plausibly be caused by degenerate ovaries.93 Yet an analysis of the removed ovaries of osteomalacia patients did not seem to confirm that their ovaries were degenerate.94 Neither theory, then, was without weaknesses.

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Contending beliefs continued. The theory of the predominantly endemic and female character of osteomalacia was generally rejected in France, where medical doctrine held that all porotic bone diseases were rachitic.95 In Central Europe, the concept of “puerperal osteomalacia” was challenged in Austria, where the renowned internist Maximilian Sternberg (1863–1934) supported the French doctrine. In 1890–91, Sternberg demonstrated that senile as well as puerperal osteomalacia − and rickets − could be cured with phosphorus in cod liver oil, coming to the conclusion that “phosphate, delivered for months in an adequate dose” was a “direct and definite remedy for osteomalacia,” thus rejecting the remedy of castration.96 This medication had been developed by Trousseau in France for children with rickets − in the belief that the phosphate, not the cod liver oil, was medically active − and it was introduced into Austria in the early 1880s.97 Sternberg also asserted the priority of developing a differential diagnosis to distinguish between osteomalacia and other bone diseases,98 a suggestion that was seized upon by the Austrian gynecologist Wilhelm Latzko (1863–1945). In 1895 in a reputable Swiss gynecological journal, Latzko challenged the assumption that osteomalacia was regionally endemic. He listed numerous individual cases in all the Austrian provinces in addition to the fifty cases he had observed in Vienna, suggesting that osteomalacia did not depend on the quality of soil or water.99 Two years later, he questioned whether osteomalacia was only a disorder of women of procreative age, pointing to occasionally affected young and frequently affected climacteric and old women. Moreover, he stated that “virile osteomalacia” seemed to be much more frequent than had so far been assumed.100 Therapies for osteomalacia were still being contested as well in the 1890s and beyond. While, quite naturally, in France “female castration” indicated by a rachitic disorder was condemned, German and Austrian opponents of the procedure − with Winckel and Latzko prominent among them − indicated the unknown cause of osteomalacia as a reason against surgery that resulted in postoperative symptoms of “masculinization,” “premature aging,” and “impotentia coeundi.”101 The critics of female castration argued that oophorectomy (and therefore the result of a non-reproductively defined femininity) meant female entropic decay. The rejection of the doctrine of ovarian causation of osteomalacia that emerged in Vienna quite probably stemmed from a conservative aversion to redefining female health in terms of (male) health as the “capacity to produce” instead of the “capacity to reproduce.” This was expressed in the rejection of techniques for controlling female

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reproductivity or, in other words, the separation of sexuality and re­ production. Therefore, gynecologists in Vienna urgently looked for different therapies. In 1895, Latzko and Julius Schnitzler experimented with “organotherapy” − after the Italians Emilio Curátulo and Luigi Tarulli had undertaken some animal experimentation on the effect of the ovaries on metabolism and stated that their results were positive − and formulated a hormonal hypothesis for the disease.102 Latzko and Schnitzler argued that if the disease was in fact caused by abnormal ovarian secretions, it could logically be treated with normal secretions, analogous to the effective therapy of “thyroid substance” for struma (swelling in the thyroid gland) and cretinism.103 “Ovarian substance” was given to four osteomalacia patients, either from the fresh ovaries of cows and pigs or in tablets made from dried animal ovaries. A fifth castrated patient was medicated in the same way to determine whether the treatment caused the condition of an already cured patient to deteriorate.104 Latzko and Schnitzler, however, came to the conclusion that the ovarian substance did not exert any effect, positive or negative, on any of the patients.105 Since the disease remained mysterious, during the 1890s its possible causation in the thyroid gland was also considered, though it was theorized only after the turn of the century by Ernst Hoennicke, who claimed in 1905 to have produced osteomalacia in rats by feeding them “thyroidin.”106 His theory of a relation between the endemic occurrence of struma (and cretinism) or Graves’ disease (morbus Basedow) and osteomalacia soon appeared to be falsified by the empirical evidence of a negative correlation between the diseases. The thyroid theory of osteomalacia was widely rejected, most gynecologists still presuming an ovarian causation of some sort. Oophorectomy continued to be regarded as the only cure for progressed cases until the 1920s. Even ardent opponents like Winckel and Latzko performed the procedure, though after 1910 sterilization was occasionally recommended instead of oophorectomy. After 1906, female castration was performed markedly less often in non-progressed cases.107 It was substituted mainly by phosphate therapy, though between 1906 and 1910 a further hormone therapy was tested. In 1906, the Italian internist Luigi Maria Bossi (1859–1919) suggested that the adrenal gland had a “contrary effect” on the ovaries108 or, in other words, that a male-defined hormone could normalize the presumed ovarian hyperfunction. He treated his osteomalacia patients with adrenaline injections, claiming to have obtained positive therapeutic results “unexpectedly.”109 His new therapy was picked up eagerly by

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a series of osteomalacia experts, some of whom confirmed his results. However, the majority of them became convinced that adrenaline had no curative effect on osteomalacia, and the injections had the undesirable side effect of producing bradycardia (slow resting heartbeat) and dyspnea (shortness of breath) in the patients,110 and its application seems to have disappeared after 1911.

F e m i n i n i t y, R a c e , C l a s s , a n d O s t e o m a l a c i a Discourse in the Twentieth Century Osteomalacia, too, had served to demonstrate the wrongs of a “passive” defined femininity in an “Oriental” setting. At the end of the nineteenth century, a group of Austro-Hungarian female health officers who were stationed in occupied Bosnia and Herzegovina decided to make the ­local “endemic” osteomalacia the starting point of a feminist campaign for “female physicians for women” in Prague and Vienna.111 While the campaign was aimed at the accreditation of female professionals, the question of osteomalacia in Bosnia served to underline the radical feminist claim for sexual reform that, at that time, could be voiced only in scientific contexts. Bosnia and Herzegovina had been occupied by Austro-Hungarian troops in 1878−79, their populations becoming immediately the target of an Austro-Hungarian civilizing mission, which meant the implementation of a general education system and one of public health and ­hygiene. While Austrian medical professionals had exhibited great animosity toward the accreditation of female physicians, the governor of Bosnia insisted on employing female professionals to improve access to public health among Bosnian Muslim women.112 This extraordinary measure was justified by the assumption that “religious shame” prevented Muslim women from consulting male doctors.113 In 1900, the feminist Austro-Hungarian health officer Theodora Krajewska (1825–1911) provided a case description concerning fifty occurrences of osteomalacia in the district of Tuzla.114 She continually emphasized that only Bosnian Muslim women suffered from osteomalacia, though in 1901 the disease was described as also being endemic in neighbouring Croatia.115 Drawing heavily on Orientalist stereotyping, Krajewska mentioned as causes of osteomalacia − besides the “damp climate,” “lack of sun,” poverty, and malnutrition − “Muslim customs” such as early marriage, veiling, extended lactation periods, and too much time indoors.116 Krajewska’s hardly reliable description of the

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“idle, passive way of living” of Muslim women who stayed in “locked and unaired rooms” all day117 rejected a femininity defined by domestic passivity and reproductive (“uterine”) sexuality. Rejecting Fehling’s identification of the “pathological function of the sexual organs” with the “function of the ovaries,” Krajewska saw “gravidity” and “other functions of the sexual sphere (sexual intercourse, menstruation, lactation)” as causes of osteomalacia.118 Her assumption of the exacerbation of the osteomalacic suffering by the (excessive) sexual demands of (Muslim) husbands was in fact new, with most osteomalacia experts holding the “female system” accountable. Obviously, Krajewska drew on a contemporary pro-birth control discourse that claimed that “hypersexual” husbands were morally responsible for the exhaustion and early death of women who had to bear many children.119 Marrying this to bone disease, her report on osteomalacia in Bosnia can be read as a plea for birth control, contemporaneously claimed by NeoMalthusians, feminists, and eugenicists, ensuring their close cooperation.120 At the same time it was an outstanding example of “imperial feminism,” reformers and feminists campaigning for female emancipation at home by indicating their modernizing achievements for “inferior” women abroad.

Conclusion In the mid-eighteenth century, osteomalacia was regarded as a deadly, though rare, disease that occurred more often in females than in males. As the Enlightenment definition of gender difference ascribed motherhood as the main purpose of women and located essential gender distinction in the skeleton, puerperal osteomalacia came to be defined as a disorder of the female pelvis that made Caesarean sections inevitable. After 1830, osteomalacia, via pelvimetry and supported by a discourse on endemic puerperal osteomalacia, was therefore considered to be in the domain of gynecological expertise and surgery. Edoardo Porro’s modified Caesarean operations, performed from 1876 onward, and Hegar’s female castration, performed from 1887 onward on osteomalacic women with healthy ovaries, were retrospectively considered to substantiate the theory of an ovarian − or in any case endocrinological − causation of the disease, whatever the risk to the individual patient. This reflected a shift in the conceptualization of gender difference, locating it in the gonads rather than in an ­anatomical distinction. Though critiques of the surgical treatment of

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osteomalacia repeatedly referred to the nutritional (deficiency) theory of osteomalacia, the theory of ovarian causation remained hegemonic until the 1930s.

notes   1  W.M. van der Scheer, “Osteomalacie und Psychose,” 845–98, Archiv für Psychiatrie und Nervenkrankheiten, 50 (1913), 845.  2 Franciscus Glissonius, De rachitide sive morbo puerili tractate, 3rd ed. (Lugduni batavorum [Leyden]: Cornelius Driehuysen & Felix Lopez, 1671), 37, 63, 132c, 135−6, 406.   3  Adolph Wilhelm Otto, A Compendium of Human and Comparative Pathological Anatomy (London: B. Fellowes, 1831), 133.  4 Ludwig Gelpke, Die Osteomalacie im Ergolzthale (Liestal: Druck von Gebr. Lüdin, 1891), 16.  5 Jutta Blönninger, Die Osteomalazie als Indikation für die bilateral Oophorektomie im späten 19. und frühen 20. Jahrhundert (Frankfurt am Main: M D , Institut für Geschichte der Medizin der Universität Erlangen-Nürnberg, 1980); see also Sengoopta, “The Modern Ovary Constructions, Meanings, Uses,” 425–88.   6  For the current medical representation of osteoporosis as a predominantly female disorder and estrogen-treatment of osteoporosis, cf. Klinge, Gender and Bones; cf. also Watkins, The Estrogen Elixir, 10–51.   7  Hermann Friedrich Kilian, Beiträge zu einer genaueren Kenntniss der allgemeinen Knochenerweichung der Frauen und ihres Einflusses auf das Becken (Bonn: Adolph Marcus, 1829), 1−2.  8 Ibid., 15.   9  Ibid., 14, 18. 10  Ibid., 12. 11  Cf. ibid., 60−2. 12  Ibid., 6−7, 26. 13 Morand, Histoire de la maladie singulière et de l’examen du cadavre d’une femme, devenue en peu de temps toute contrefaite par un ramollissement général des os: communiqueé à la Faculté de Médecine de Paris, dans plusieurs assemblées du prima mensis (Paris: Chez la Veuve Quillau, 1852), [20]−[21]; drawing of Mme Supiot, s.p. 14  J.P. Hoebeke, Mémoires et observations pratiques de chirurgie et d’obstétrique (Bruxelles: Société encyclographique des sciences médicales, 1840), 15−6. 15  Ibid., 41. 16  Cf. Gelpke, Die Osteomalacie im Ergolzthale, 49−52.

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17  Masakiyu Ogata, “Zur Behandlung der Osteomalazie,” Beiträge zur Geburtshilfe und Gynäkologie 20 (1915), 90−6, 93−4. 18  Hermann Friedrich Kilian, Das halisteretische Becken in seiner Weichheit und Dehnbarkeit während der Geburt (Bonn: Adolph Marcus, 1857), 80–93; Franz von Winckel, Klinische Beobachtungen der Dystokie durch Beckenenge (Leipzig: Verlag von S. Hirzl, 1882), 2−46c, 52−5; Carl Everke, “Die Osteomalacie in Westfalen,” Monatsschrift für Geburtshuelfe und Gynaekologie 16 (1907), 187−97. 19  Ludwig Gelpke, Die Osteomalacie im Ergolzthale, 40c. 20  Ibid., 42. 21  For example, around Heidelberg, cf. Ferdinand Adolf Kehrer, “Über Osteomalacie,” Centralblatt für Gynäkologie 13 (1889), 731−2. 22  Masakiyo Ogata, “Zur Behandlung der Osteomalazie,” Beiträge zur Geburtshilfe und Gynäkologie 14 (1909), 492−7; cf. also Masakiyo Ogata, “Untersuchungen über den Stoffwechsel mit Rücksicht auf die Ätiologie der Rachitis und Osteomalazie,” Beiträge zur Geburtshilfe und Gynäkologie 20 (1915), 90−8. 23  The cumulation of osteomalacia cases owing to the rejection of the concept of “endemic osteomalacia” in Austria was never signified as “endemic”; however, cf., for example, Heinrich Fischer,“Casuistischer Beitrag zur Behandlung der Osteomalacie,” Prager Medizinische Wochenschrift 19 (1894): 425−6; Heinrich Fischer, “Weitere Beiträge zur Behandlung von Osteomalazie,” Prager Medizinische Wochenschrift 20 (1895), 387−8. 24  Žitný ostrov (Rye Island) near Bratislava (then Pressburg, Slovakia, then Hungary), cf. Desiderius von Velits, “Ueber die Heilung der Osteomalacie,” Zeitschrift für Geburtshülfe und Gynäkologie 23 (1892), 321−7; in the district of Tuzla in Bosnia, cf. Theodora Krajewska, “Osteomalacie in Bosnien (Kreis Dolnja Tuzla),” Wiener Medizinische Wochenschrift 50 (1900), 1785−8, 1824−8, 1893−6, 1930−5, 1982−6, 2022−4, 2074−8, and 2134−8; in Sarajevo and its vicinity, Bosnia, cf. Theodora Krajewska, “Jahresbericht der Amtsärztin Dr. T. Krajewska in Sarajevo für das Jahr 1902,” Wiener Medizinische Wochenschrift 38 (1903), 1778−82, 1829−31, 1872−6, and 1926−30; in the comitatuses of LikaKrbava and Modrus-Fiume in Croatia, Hungary, cf. L. Vrbanić, “Ueber Osteomalacie in Kroatien,” Centralblatt für Gynäkologie 25 (1901), 922−4; in Galicia, cf. Bernard Englaender, “Adrenalin bei Knochenerweichung,” 445−51, Zentralblatt für Gynäkologie 55 (1909), 450. 25  An analysis of one of the then-leading Austrian medical journals, Wiener Medizinische Wochenschrift, from 1851 to 1920 shows that 3.7 per cent of all contributions dealt with what today are considered disorders of the

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musculoskeletal system. Discussion revolved around firstly the possible syphilitic causation of bone and joint afflictions and of rheumatism, gout, and arthritis; after 1870 the focus was on “osteomalacia” used as an umbrella term for various bone disorders such as osteoporosis, osteopenia, osteomalacia, and occasionally also rickets. 26  Cf. H. Schlesinger, “Die Schmerzhaftigkeit des Kopfskelettes bei der Hunger­ osteomalacie,” 822−3, Wiener Medizinische Wochenschrift 70 (1920): 822c. 27  For example, case 29 (Rosenstock, Arbeiterswitwe) in Everke, “Die Osteomalacie in Westfalen,” 187–97, Monatsschrift Für Geburtshülfe und Gynäkologie 26 (1907): 188, 194c. 28  For the “female skeleton” and its Enlightenment representation, cf. Schiebinger, Schöne Geister. Frauen in den Anfängen der modernen Wissenschaft, 270−288; cf. also Honegger, Die Ordnung der Geschlechter (1991). 29 Kilian, Beiträge zu einer genaueren Kenntniss der allgemeinen Knochenerweichung der Frauen, 8c. 30  Ibid., 20. 31 Martin, The Woman in the Body. 32  Tuana, “Der schwächere Samen. Androzentrismus in der Aristotelischen Zeugungstheorie und der Galenschen Anatomie,” 203−23, in Das Geschlecht der Natur. Feministische Beiträge zur Geschichte und Theorie der Naturwissenschaft, edited by Barbara Orland and Elvira Scheich (Frankfurt am Main: Suhrkamp, 1995), 203−23. 33  Larsson, “Historical Perspective on Breastfeeding and Nursing,” 14, The Orthodontic Cyber Journal, June 2006, P D F , 14; http://orthocj. com/2006/06/historical-perspective-on-breast-feeding-and-nursing/ 34  Schmid, “Sauber und schwach, stark und stillend,” Der weibliche Körper im pädagogischen Diskurs der beginnenden Moderne”, 55−77, in Von der Auffälligkeit des Leibes, edited by Farideh Akashe-Boehm (Frankfurt am Main: Suhrkamp, 1995): 55–77. 35 Allen, Feminism and Motherhood in Western Europe 1890–1970, 17–57. 36  Cf. Sengoopta, “The Modern Ovary Constructions,” 428. 37  “Medvei 1983: 215” (English translation), quoted by Oudshoorn, Beyond the Natural Body: An Archaeology of Sex Hormones, 8. 38  However, popular and even professional discourse remained fixated upon the uterus as the female master organ. A medical concern for the female gonads is rarely manifest before the 1860s when British and then German physicians began to warn against the settlement of white women in tropical colonies, assuming that the tropical climate caused the degeneration of the ovaries and, as a consequence, infertility in white women; cf. Tilt, Health in India for British Women, and the Prevention of Disease in Tropical

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Climates (London: J. & A. Churchill, 1874); Grosse, Kolonialismus, Eugenik und bürgerliche Gesellschaft in Deutschland 1850–1918 (2000). 39 Laqueur, Solitary Sex: A Cultural History of Masturbation (2003). 40  In Protestant countries, including Germany and Switzerland, masturbation was prominently listed among those vices, an idea, however, not followed in Roman Catholic France or Austria where a modernist medical discourse continued to consider masturbation as a prerequisite of male health, while it was viewed as noxious for women. 41  Cf. Christina von Braun, Nicht ich. Logik, Lüge, Libido (1990). A systematic comparison of hysteria (as a presumed disorder of the uterus) and osteomalacia (as a presumed disorder of the ovaries) would be of great interest; the problem, however, is complex because at least after 1880, French (Charcot) and Central European (Breuer, Freud) medical theory focused on “male hysteria.” Therefore, in Central European medical theory (but not in hegemonic and popular scientific discourse), osteomalacia was the only exclusively female disorder. 42  Hermann Friedrich Kilian, Operationslehre für Geburtshelfer (2 Theile). 1. Die operative Geburtshülfe (Bonn: Eduard Weber, 2nd ed., 1849), 702. 43  For a collection of methods, cf. Kilian, Operationslehre für Geburtshelfer. 1. Die operative Geburtshülfe, 613−93. 44  P.-L. Lonex, “Opération césarienne,” Annales de médicine belge et étrangère 3 (1841), 85−6. 45  “Réflexions sur P.-L. Lonex, ‘Opération césarienne,’” Annales de médicine belge et étrangère 3 (1841), 86c. 46 Kilian, Operationslehr für Geburtshelfer. 1 Die operative Geburtshülfe, 737−9. 47  Rudolf Virchow, “Das normale Knochenwachstum und die rachitische Störung desselben,” 409−507, Virchows Archiv 5 (1853), 492. 48  Ibid., 493−4. 49  Ibid., 492. 50  Ibid., 492c. 51  See, for example, Hermann Senator, “Die Krankheiten des Bewegungsapparates,” 3−212, in Handbuch der Speciellen Pathologie und Therapie, ­edited by Hugo von Ziemssen, vol. 13, part 1 (Leipzig: Vogel, 1875), 195−212; Richard Volkmann,“Die Krankheiten des Bewegungsapparates,” in Handbuch der allgemeinen und speciellen Chirurgie mit Einschluss der topographischen Anatomie, Operations- und Verbandslehre, edited by Franz von Pitha and Theodor Billroth, vol. 2, part 2 (Stuttgart: Verlag von ­Ferdinand Enke, 1882 [1873]), 234–490; Adolf Strümpell, “Die Osteomalazie,” in idem, Lehrbuch der Speziellen Pathologie und Therapie der inneren Krankheiten für Studierende und Ärzte, 2 vols, 162–7 (Leipzig: Verlag von

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F.C.W. Vogel 1922 [1884]), vol. 2, 162c., and Oswald Vierordt, “Rhachitis und Osteomalacie,” in Specielle Pathologie und Therapie, edited by Hermann Nothnagel, vol. 7/2 (Vienna: Hölder, 1903), 1−147. 52 Kilian, Das halisteretische Becken, 28. 53  Carl Conrad Theodor Litzmann, Die Formen des Beckens, insbesondere des ­engen weiblichen Beckens nach eigenen Beobachtungen und Untersuchungen nebst einem Anhange über die Osteomalacie (Berlin: Georg Reimer, 1861). 54  Ibid., 125c. 55  Ibid., 134−6. 56  Male cases as a rule were considered to be insignificant; however, cf. Rohkamm, Ein Fall von Osteomalazie beim Manne unter besonderer Berücksichtigung der Beziehung zum Zahnsystem (Berlin: M D , 1932). 57  cf. Winckel, Klinische Beobachtungen der Dystokie, 2−3. 58  Litzmann was the first German gynecologist to systematize the knowledge on pathological pelvises as a relative risk factor in deliveries, differentiating between small pelvises with and without “deviation from the normal form.” The former were differentiated into four classes, the fourth of which, the “folded pelvis,” contained the dysfunctional osteomalacic and the deformed rachitic types; cf. Litzmann, Die Formen des Beckens, 37−94. 59  Ibid., 7. 60 Winckel, Klinische Beobachtungen der Dystokie, 18. 61  Carl Hennig, “Die höheren Grade der weiblichen Osteomalacie”, 494– 538, Archiv für Gynäkologie 5 (1873), 535−8. 62  Franz von Winckel, Lehrbuch der Geburtshülfe einschließlich der Pathologie und Therapie des Wochenbettes, 2nd ed. (Leipzig: Verlag von Veit & Comp., 1893 [1889]), 441−5. 63 Winckel, Klinische Beobachtungen der Dystokie, 46c. 64  Cf., for example, Allen, Feminism and Motherhood in Western Europe 1890–1970. 65  Cf. Brigitte Fuchs, “Rasse,” “Volk,” Geschlecht. Anthropologische Diskurse in Österreich (1850–1960), 90c. 66  Cf. Shen, “Feminist Redemption of the Witch,” 30. 67  See Jordanova, Sexual Visions, 79; generally, cf. also Plumwood, Feminism and the Mastery of Nature, 104−19. 68 Blönninger, Die Osteomalazie als Indikation für die bilaterale Oophorektomie, 35−9. 69 Oudshoorn, Beyond the Natural Body, 19. 70  Sengoopta, “The Modern Ovary Constructions,” 437. 71  cf. Carl Mayrhofer, “Sterilität, Entwicklungsfehler und Entzündungen des Uterus,” 1−194, Handbuch der allgemeinen und speciellen Chirurgie mit

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Einschluss der topographischen Anatomie, Operations- und Verbandslehre, edited by Franz von Pitha and Theodor Billroth, vol. 4, part 1A (Stuttgart: Verlag von Ferdinand Enke, 1882), 10. 72  Ibid., 9c. 73  Cf. Hermann Fehling, “Ein Kaiserschnitt nach Porro bei Osteomalacie mit günstigem Ausgange,” Archiv für Gynäkologie 22 (1882), 399−408. 74  cf. Blönninger, Die Osteomalazie als Indikation für die bilaterale Oophorektomie, 10−2. 75  Ibid., 13; Hegar assumed that disorders of the ovaries as the master organs of the female organism caused hysteria, the cure of which, on the other hand, depended on the preservation of the uterus. 76  As a consequence of the idea that the ovaries and the uterus were not (directly) related, Hegar had suggested curing various physiological disorders and hysteria by “female castration,” assuming that the excision of presumably degenerated ovaries would produce a normal condition of the uterus and, consequently, of the “female mind”; cf. Sengoopta, “The Modern Ovary Constructions,” 429−31. 77  Hermann Fehling, “Über Kastration bei Osteomalacie (Bericht über den zweiten Kongress der Deutschen Gesellschaft für Gynäkologie in Halle, 23–26 Mai 1888),” Centralblatt für Gynäkologie 12 (1888), 427. 78 Blönninger, Die Osteomalazie als Indikation für die bilaterale Oophorektomie, 31, 35−9. 79  Ibid., 35−9. In 1909, the first experiments with ovariotomies, that is, castration of osteomalacia patients by X-ray radiation, were undertaken in Russia; cf. Literaturbericht S.G. Saretzky, “Ein Versuch der therapeutischen Röntgenisierung der Eierstöcke” (Journal für Geburtshilfe und Gynäkologie 1908, St. Petersburg 1908, russ.), 111−12, Zentralblatt für Gynäkologie 34 (1910), 111. 80  Hermann Fehling, “Ueber Wesen und Behandlung der puerperalen Osteomalakie,”171−96, Arch. Gyn. 39 (1891), 191−2; see Sengoopta, “The Modern Ovary Constructions,” 436. 81  Hermann Fehling, “Weitere Beiträge zur Lehre von der Osteomalakie,” 472−98, Arch. Gyn. 48 (1895), 487. 82  cf. Wilhelm Ladenburger, Sechs Fälle von Osteomalazie (Tübingen: M D , 1904), 13. 83  See Bergmann, “Die verhütete Sexualität: Frauen zwischen Gebärzwang und Gebärverbot im 20. Jahrhundert,” 29. 84  For example, Wilhelm Mensinga, “Zur Prognose des eheweiblichen Lebens,” Hebammen-Zeitung. Organ des Unterstützungs-Vereines für Hebammen 7, no. 15 (15 August 1893), 113−4.

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  85  See Alfred Stieda, “Zur osteomalacischen Lähmung,” Monatsschrift für Geburtshülfe und Gyäkologie 8 (1898), 1−20.   86  van der Scheer, “Osteomalacie und Psychose,” Archiv Für Psychiatrie und Nervenkrankheiten 50 (1913), 845−985; 51 (1913), 79−208.  87 Gelpke, Die Osteomalacie im Ergolzthale.  88 Ibid., 49.  89 Ibid., 32.   90  Cf. F. Roloff, “Ueber Osteomalacie,“ Virchows Archiv 46 (1869), 305−16.  91 Gelpke, Die Osteomalacie im Ergolzthale, 48.  92 Ibid., 49.   93  Cf. Hugo Sellheim, “Kastration und sekundäre Geschlechtsmerkmale,” 409−12, Beiträge zur Geburtshilfe und Gynäkologie 6 (1901), 412; cf. also O. Falk, “Osteomalakie und innere Sekretion der Osteomalacischen,” 374−8, Zentralblatt für Gynäkologie 34/1 (1910), 374.   94  Cf. Guillaume Rossier, “Anatomische Untersuchung der Ovarien in Fällen von Osteomalacie,” 606−10, Archiv für Gynäkologie 48 (1895), 606−10; cf. also Gustav Bulius, “Osteomalacie und Eierstock,” 138−66, Beiträge zur Geburtshilfe und Gynäkologie 1 (1898), 164.   95  See Léon Bernard, “Nature de l’ostéomalacie (Ostéophathie myélogène),” Revue de médicine 30 (1910), 345–64; S. Bonnamor / Albert Badolle, “Le syndrome oestéomalacique. Ses différentes causes,” Revue de médicine 33 (1913), 889–912. In France, however, osteomalacia ­became considered a more malignant form of rickets, with osteomalacia also becoming a diagnosis for children with severe rickets at the end of the century.   96  Maximilian Sternberg, “Ueber Diagnose und Therapie der Osteomalacie,” Zeitschrift für klinische Medizin 22 (1893), 297−8.   97  Sternberg, “Ueber Diagnose und Therapie der Osteomalacie,” 265−313.  98 Ibid., 300−13.   99  Wilhelm Latzko, “Zur Diagnose und Frequenz der Osteomalacie,” 152−68, Monatsschrift für Geburtshülfe und Gynäkologie 1 (1895), 163−4; cf. also Wilhelm Latzko, “Beiträge zur Diagnose und Therapie der Osteomalacie,” 571−89, 590−608, Monatsschrift für Geburtshülfe und Gynäkologie 6 (1897): 571c. 100  Wilhelm Latzko,“Beiträge zur Diagnose und Therapie der Osteomalacie,” 571−89, 590−608, Monatsschrift für Geburtshülfe und Gynäkologie 6 (1897), 572. 101  cf. Ernst Alterthum, “Die Folgezustände nach Kastration und die sekundären Geschlechtsmerkmale,” 13−51, Beiträge zur Geburtshilfe und Gynäkologie 2 (1899), 21.

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102 Blönninger, Die Osteomalazie als Indikation für die bilaterale Oophorektomie, 65−73. 103  Wilhelm Latzko and Julius Schnitzler, “Zur Organotherapie bei Osteomalacie,” 587−92, Deutsche Medizinische Wochenschrift 23 (1897), 588. 104  Ibid., 591c. 105  Ibid., 592. 106  Ernst Hoennike, Über das Wesen der Osteomalacie und seine therapeutischen Consequenzen. Ein Beitrag zur Lehre von den Krankheiten der Schilddrüse. Nebst Bemerkungen über den seelischen Zustand bei der Knochenerweichung (Halle: Abhandlungen auf dem Gebiet der Geistes- und Nervenkrankheiten, 1905). 107 Blönninger, Die Osteomalazie als Indikation für die bilaterale Oophorektomie, 31. 108  cf. Falk, “Osteomalakie und innere Sekretion der Osteomalacischen,” 378. 109  Luigi Maria Bossi, “Die Nebennieren und die Osteomalacie,” 505−44, Archiv für Gynäkologie 83 (1907), 509. 110  Cf., for example, Englaender, “Adrenalin bei Knochenerweichung,” 450. 111 Gamper, Die Ärztin gehört für die Frau, 26. 112  Fuchs, “Orientalising Disease. Austro-Hungarian Policies of ‘Race,’ Gender and Hygiene in Bosnia and Herzegovina, 1878–1914,” 74−83. 113  For the erroneous character of this assumption, see Brigitte Fuchs, “Popularizing Hygiene: Austro-Hungarian Female Health Officers and Women’s Health Issues in Bosnia and Herzegovina 1890–1918,” 936. 114  Theodora Krajewska, “Osteomalacie in Bosnien (Kreis Dolnja Tuzla),” Wiener Medizinische Wochenschrift 50 (1900), 1785−8, 1824−8, 1893−6, 1930−5, 1982−6, 2022−4, 2074−8, and 2134−8. 115 Vrbanić, “Ueber Osteomalacie in Kroatien,” 922. 116  Theodora Krajewska, “Osteomalacie in Bosnien (Kreis Dolnja Tuzla),” 1786, 1824. 117  See Theodora Krajewska, “Jahresbericht der Amtsärztin Dr. T. Krajewska,” 567. 118  Ibid., 1827. 119 Bergmann, Die verhütete Sexualität. Die Anfänge der modernen Geburtenkontrolle, 168−70. 120  Neo-Malthusians, who formed an international movement after 1880, saw social reforms based on eugenic improvements in the working classes and by restricting family size, see Allen, Feminism and Motherhood in Western Europe 1890–1970, 188–205.

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6 Disciplining Male Bodies: Infertility and Medicine in Germany in the Decades after the Second World War Antje Kampf Late-twentieth-century biomedical technologies that were intended to “treat” infertile men, along with recent popular debates about men’s health, have cast a light on male involvement in reproduction along with the cultural meanings attached to it. Concern over reproduction and health has traditionally been tied to women when infertile women have been understood to “bear the burden of blame and social scrutiny.”1 Scholars have explored how women’s bodies have been medicalized and cast as deviant (as Rebecca Godderis also discusses in this volume; see chapter 12) from the supposedly normative, that is healthy, male body.2 In this respect, men have been largely disassociated from processes of reproduction and their failing reproductive health has not entered mainstream debate as much as it has been traditionally the case for women. Although the reframing of infertility as an issue of importance to men and the development of ways for couples to deal with men’s reproductive role and the concomitant medical knowledge of it may seem to be phenomena unique to the late twentieth century, this is not the case. With the aim of bringing men back into the history of reproduction and by overcoming the “blind spot”3 of research into the gendered reproductive historical writing,4 this chapter discusses how the male reproductive body became of concern to a range of medical disciplines and how it was classified and normalized in the 1950s and 1960s by using the example of Germany. It deals with the question of infertility; impotence, while an important subject, is not part of this analysis.

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The period immediately before the onset of late-twentieth-century reproductive technology has been sidelined in the scholarship.5 The postwar decades do not seem to have been of much interest, the important points of reference falling on either side of the period. The anti- and pro-natalist eugenic agenda of the Nazi regime officially came to an end with the Nuremberg trials; andrology, the “science of man,” established itself officially as a medical discipline only after the 1970s; public debates about reproductive technology such as in vitro fertilization (I V F ) of women began in the late 1970s; technologies catering to men’s dysfunctional reproductive bodies, such as intracytospermatic insemination (I C S I ),6 emerged in the 1990s. But there are several advantages to focusing on the historical epistemology of male infertility in the interim years (the 1950s and 1960s) and using Germany as an example: it allows us to analyze the contingencies and ruptures of the (re)formative years of the medical profession. After the demise of pro-natalist research and anti-natalist practices under the Nazi regime, the profession increasingly directed its gaze at male bodies at a time when “fertility laboratories” were set up at university clinics and men sought advice about the state of their reproductive capacities. The chapter also facilitates a reconsideration of the beginnings of andrology and, finally, permits a contextualization of a specific nationalist history on the interrelation of fatherhood and body politics. This consideration draws upon Michael Foucault’s concept of the dispositif, by which he meant the enhancement and maintenance of power and knowledge within the social body by various institutions, mechanisms, and disciplinary structures.7 Foucault’s concept helps us to understand the relationship between the infrastructure of disease (which includes diverse fields such as medical disciplines, politics, and the judiciary), the technologies involved (medical guidelines, infertility tests, and testicle measurements), and the related materials (the testes and seminal fluids). This approach makes it possible to investigate the so far little researched ways in which the male body and, by extension, male reproduction were defined in the post-war period by competing and constitutive medical disciplines, in Adele Clarke’s sense of “disciplining reproduction.”8 Foucault also reminds us that the historian’s task should be to question illusions of the solidity, firmness, and stability of the body and to interrogate the discourses that construct them.9 Thus, the chapter queries the relation of infertility to the ideal social and biological role of the father and examines the correlation that existed between the hegemonic masculine ideals that Thomas Wendelboe focuses on in this

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volume (see chapter 10) and the associated characteristics of invulnerability, fertility, and health.10 Researching this “hidden” story of male infertility has been challenging because restrictions have been placed on patient sources and case records have been destroyed. Thus, leaving an interrogation on the perspectives of men to ongoing future research, this chapter focuses for now on the medical and socio-political perspective. A brief clarification at this point: this chapter will not dispute that infertility has been of real concern to couples nor does it tackle the question of how infertility was defined in the past, variously as a medical, psychological, or socio-­ cultural condition. Rather, this chapter interrogates how a (medical) condition has become a health issue (somewhat similarly to the way Barbara Brookes examines disability in chapter 7 in this volume), discussing the ways in which medical debates about male infertility created a gendered construction of male healthy / unhealthy bodies. Using various sources, including medical articles, medical textbooks, congress reports, and clinical notes from the “fertility clinic” at the dermatology department at the University of Hamburg,11 the chapter is divided into three parts. The first focuses both on the constitution of a male reproductive subject as part of a competitive environment of medical disciplines and on diagnostic taxonomies of male infertility in the biomedical context and in terms of power relations. The second part analyzes the ways in which the reproductive body politic has historically been correlated with normative male identities such as fatherhood. The last part pursues some of the normative concepts of male bodies that were integral to the conceptualization of male infertility and biomedical knowledge in the decades after the Second World War.

Male Reproduction and Medical Disciplines The features of the medical landscape of 1950s and 1960s in Germany have been described as disparate, with a distinction drawn between a  “broken” profession after the fall of the fascist regime and the Nuremberg Doctor Trials in 1946, which revealed the extent to which physicians had conducted unethical human experiments and euthanasia, and the adoption of “modern” medical paradigms. These initially included, among others, a disavowal of medical intervention based on population politics and a (re)turn to medical intervention based on the individual patient.12 Medical knowledge about the male reproductive body in Germany at the time was distributed across several disciplines,

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similar to the situation for medical knowledge about osteomalacia as described by Brigitte Fuchs in chapter 5 of this volume; each of the disciplines demanded authority over the reproductive male body. The role of the male reproductive system in problems of conception and infertility was understood long before the 1950s.13 Sperm, as the crucial element in insemination, had been central to practices conducted by gynecologists in response to the demands of infertile couples for help with their plight. Men’s fluids had become part of research into sperm, their genital organs scrutinized by dermatologists in the treatment of venereal disease, and their endocrinological systems examined by sexologists and physiologists. Paradoxically, the field of gynecology produced the first medical professionals willing to turn their eyes to male reproductive problems, as part of the clinical treatment of infertile couples.14 Checking the capacity of a man to procreate before undertaking the much more invasive diagnostic technologies necessary to ­investigate the functioning of a woman’s reproductive organs was considered proper gynecological conduct in the years after the Second World War.15 Their only measurement was a test called the post-coital or Sims-Huhner-test, which detects the presence of sperm in the mucus examined up to four hours after intercourse. The test was used before the war and remained in common use throughout the post-war period. On the basis of the findings of the test, by the late 1940s gynecologists had estimated that the infertility of up to thirty to forty per cent of all sterile families was supposedly due to men. As early as 1951, stirred by these findings, the eminent German gynecologist Harald Siebke16 insisted on the absolute need for the estab­ lishment of a field of andrology to assist childless couples, noting the growing complexity of diagnosis and possible treatment options in cases of male infertility. Treatment was to remain infrequent until at least the late 1960s. But while the andrology and gynecology medical clinics that were established at some universities cooperated closely, sources indicate that many gynecologists did not follow Siebke’s call, attempting instead to retain the responsibility for diagnosing infertile men within the medical discipline of gynecology well into the 1960s. In his opening speech as first president of the newly established Deutschen Gesellschaft zum Studium der Fertilität und Sterilität (German Society for the Study of Fertility and Sterility, D G S F S ) in 1957, Richard Fikentscher outlined that gynecologists, because of their long-standing work with and knowledge of reproductive medicine, were able to extend their capability to care for men. Fikentscher emphasized that these

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specialists more than others were inclined to consider the well-being of couples and male patients as a whole instead of turning infertility into an andrological laboratory affair. Was it not the case, Fikentscher queried, that a man could have a perfectly “normal” spermiogram and ­intact potency yet still be the cause of a sterile marriage because of something inherent to his whole behaviour? In making this suggestion, Fikentscher blurred the lines between what was defined as normal and what was defined as pathological.17 Using a rhetoric of male empathy, some gynecologists argued that investigative medical consultation should be kept to a minimum to avoid the further loss of a patient’s “manly dignity,” a loss witnessed often in men who conflated the ability to perform the sexual act (potentia coeundi) and the ability to procreate (potentia generandi).18 Gynecologists, they argued, should thus be the first in line to help couples by turning their gaze on men: male infertility had to be diagnosed and “treated.” From gynecologists’ perspectives, however, the treatment was restricted to the female body with the use of the “portio cap” procedure, a procedure in which sperm collected by the partner was placed in the cap and inserted directly onto the cervix.19 In addition, they insisted on their expert authority on reproductive issues: was it not they who, in earlier gynecological research on the processes of ovulation, had overturned the general consensus that a man with even a single sperm in his ejaculate was fertile, stimulating further research into the male reproductive system?20 Gynecologists did not retain their limited hold on investigating men’s infertility. Dermatologists, too, insisted on playing a major part in caring for men’s reproductive dysfunctions. They were impelled by the closeness of their discipline to aspects of venereology and the treatment of infectious diseases such as gonorrhea and syphilis, which also targeted organs important for reproduction.21 In fact, dermatologists from the university clinic of Bonn, such as Rudolf Doepfmer (1920–1965), noted at the first conference of the DGSFS in 1959 that the lack of information on the effects of infectious diseases on the testes – and consequently on male fertility – was not so much a consequence of the absence of a pathological reality as of the dispersal of patients over different medical disciplines with various methodologies, resulting in disparate findings.22 Unlike the gynecologists and andrologists, whose predominant interest was in defining sperm quality as they saw it, dermatologists insisted on  the significance of obstructions of the tubes and canal systems of the testis stemming from a variety of infectious diseases.23 Within the still-unresolved puzzle of the origin of male infertility, testis diagnosis

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became one of the main areas of dermatological interest in the male reproductive body. Andrology itself had emerged as a subdiscipline of dermatology in the late 1950s24 and increasingly claimed dominance over knowledge of the male reproductive body. Extending their stakeholding, they ­suggested that the dermatological heritage would be of no use in determining testis histology or sperm morphology.25 The creation of this subdiscipline was spurred by several developments: research into veterinary research in the 1930s, specifically in new understanding of sperm morphology in bulls (polyspermy); the establishment of the related technologies of veterinary cryoconservation26; and the absorption of earlier biometrical research stemming from the Weimar Republic and 1930s national and international research.27 The sole focus of the discipline was the male body, with an initially strong emphasis on morphological and, by the 1960s, biochemical examinations of the sperm and its relation to endocrinological research. This made andrologists experts in their own right. As one dermatologist put it, mocking gynecologists, you cannot really diagnose fertility simply by detecting a tired sperm passing under the microscope.28 Andrology was officially established as a discipline in its own right in the mid-1970s, primarily through the efforts of dermatologist Carl Schirren, who set up one of the first andrological laboratories at the university clinic in Hamburg, followed by several others at university clinics in western Germany, for example in Berlin, Marburg, Cologne, Giessen, and Freiburg.29 Despite this, andrology struggled for decades to emancipate itself from more dominant disciplines.30 With an expansion of their area of expertise from infertility (impotentia generandi) to impotence (impotentia coeundi) and many other aspects of psychology and psychotherapy, andrologists also worked in tandem with sexology research, which had slowly (re)established itself by the mid-1960s from its academic demise during the Nazi regime.31 Also staking a professional claim in the post-war decades was urology, a subdiscipline of surgery. Urologists, too, searched for causes of, and devised treatment options for, male infertility. With a side glance at gynecology and dermatology, these specialists stressed that diagnosis of male infertility was not a simple matter of investigating ejaculate quality but, as renowned urologists Hans Boeminghaus and Herbert Klosterhalfen insisted, required a “methodical examination process” specific to their discipline.32 Urologists also resisted dermatologists’ demand to add andrology to their speciality training. They argued that

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only urologists would know how to conduct testis biopsies,33 make conclusions about the inner workings of organs, and perform endocrinological examinations such as the diagnosis of gonadotropine, hormones that stimulate the gonads, in the urine to find testosterone deficiencies in the male system.34 Urologists drew from a longer tradition of diagnostic taxonomies on male genital problems to strengthen their discipline,35 a discipline that they were still attempting to consolidate after the Second World War.36 By the 1960s, urologists, like andrologists, had widened their thematic approach by increasingly turning to problems of male infertility associated with embryopathic changes, insisting on early diagnosis to facilitate surgical intervention.37 Illustrative of these efforts to strengthen the importance of their field is a graphic representation of the male reproductive body from 1970, which reveals the male body as a minefield, a subject demanding urological intervention and the employment of diagnostic techniques.38 In spite of or because of this competition, researchers came to understand the diversity and complexity of reproductive issues and the apparent need for professionalization. In Germany, however, the official founding of the umbrella organization D G S F S in 1957, which aimed at connecting these different strands of medicine, came much later than the equivalent introduction of “reproductive medicine” in the United States, the United Kingdom, and France around the end of the war. This delay can be attributed to the troubled history of the biopolitical eugenic agenda of medical research under the Nazi regime.39 The r­ emit of the D G S F S was to study reproductive medicine in an interdisciplinary way that included a consideration of male reproduction spanning the disciplines of urology, gynecology, dermatology, veterinary medicine, forensic medicine, and sexology. One of the goals of the society was to loosen the hold of gynecology on reproductive medicine to embrace growing specialist diagnostics and to engender a specialist knowledge by providing “sterility coaching in a modern way.” This involved finding a joint approach to diagnosis and subsequent treatment, derived from the individual vita sexualis and a “general psychology of the marriage situation.”40 It was a paradoxical aim, given that the society supported the idea that patients should work with only with one physician to avoid inducing “psychological sterility” in the couple (by which it really meant the man) through too much investigation. Recognition of further research into the nature and impact of male infertility remained limited in the early years of the society; nevertheless, by the late

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1970s its work had increasingly been directed toward andrological empirical findings that focused on male responsibility for a couple’s infertility. Professional control over male bodies evolved amidst increasingly competetive claims of disparate different medical disciplines. Relatedly, their intra-disciplinary dispute also medicalized men.

F at h e r h o o d a n d B o dy P o l i t i c s “Fatherhood was not a creation of ‘insemination [Zeugungsvorgang]’ … a short-term act, but of society,” asserted Hans Giese, director of the Institute for Sexual Research in Frankfurt (later Hamburg), at a 1957 court hearing on the repeal of the homosexuality law §175 StGB.41 When a man visited a clinic in search of answers to a couple’s infertility it was not merely a private affair, and the medical emphasis on the importance of men in childless marriages was not a purely medical matter. In the post-war decades, the nature of infertility was tied up with larger population politics, a mounting debate about the role of families, and sociocultural ideals of normative masculinity, as illustrated by Giese’s insistence on social fatherhood. Just after the war, physicians in Germany responded to requests by men who had been forced to undergo sterilization under the Nazi regime to restore fertility through surgery.42 This was a mainly hidden decision by men, a delicate matter at a time at which there was a growing public debate about returning war veterans and the status of their weakened health and concomitant masculinity.43 As early as 1946, to secure against a population drop owing to the loss  of human life through war and the concomitant lack of men of ­reproductive age,44 the Allied Control Council Marriage Law allowed for ­divorce in cases of serious illness, which included infertility, echoing former eugenic parlance.45 Christian Democrat Franz Joseph Wuermeling, heading the new Bundesministerium für Familienfragen (Ministry for Family Affairs) under Chancellor Konrad Adenauer in 1953, invoked former national populist jargon to call for a rise in the birthrate. He also depicted the lack of births as a disease of the population despite a baby boom that lasted until the mid-1960s.46 In the immediate post-war years and into the early 1950s, society’s fundamental building block – the core family based on the principle of paternal authority – seemed to be under threat.47 Scenes of men returning from war camps to find children they could not have conceived and distant fathers who were incapable of having an emotional reunion with their female partners destabilized the normative social status of men as

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fathers in post-war Germany.48 This development was also spurred by changes in gendered work relations, a new Common Law (1949) that reduced fathers’ sole rights to make family decisions, and an increase in divorces.49 Restoration of the idealized “natural order” of the family, with a reconstruction of gender roles and identities, would counter this sociopolitical instability. An indication of this trend can be derived from official demographics: declining birthrates were correlated with the ­expansion of female work, not with (potential) male infertility. In fact, male infertility stood far removed from official political debate, wherein the dominance of men as breadwinners and fathers loomed large, and when criminal law still defined homosexuality as an abnormality.50 The common idea of a normative male, with attributes of heterosexuality, fertility, and fatherhood, became an issue outside of practitioners’ rooms and patients’ homes. It was manifest in judicial and personal insurance cases, adoption procedures, and child-income decisions.51 Paternity cases, for example, had been on the increase since the 1950s, following the German high court’s decision to allow single-parent families to file parentage claims against men (1958). The interrelated dimensions of sociopolitical constructions of sex, power, and men’s reproductive bodies from the 1950s onwards can be traced in the emergence of ideas about stress-related psychosocial effects on genital function leading to male infertility.52 This debate about the effects of psychological stressors on men’s reproductive functioning, for example on semen production, (re)emerged at a time when socioeconomic problems and the characteristics of modern managerial employment were raising concerns about men’s health.53 In the context of the social strain of post-war economic reconstruction and Germany’s Wirtschaftswunder, doctors dubbed genital dysfunction “job impotence” because it was believed to be induced by intensive workloads. Sources indicate that male infertility was addressed predominantly in terms of its effect on members of the middle class (such as researchers, businessmen, academics, and clerical workers), that is, those who were in danger of succumbing to the potentially emasculating effects of non-industrial work.54 Stress-related factors increasingly played a crucial role in diagnosis, as illustrated by the questionnaires that patients were required to fill out before making a spermiogram.55 This medical persuasion corresponded to changes in the judicial area: the impact of stress factors leading to loss of fertility was recognized by the Bundessozialgericht (Federal Social Court) in 1959 as an infringement on the personality that could

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lead to mental problems. These, in turn, were believed to have an impact on the quality of an individual’s work.56 The diagnosis of infertility was on the rise in post-war Germany. At the time of the Federal Court ruling it was believed that men were responsible for forty per cent of all cases of couples’ infertility.57 Yet although research was expanding and diagnostic techniques were increasingly available, the treatment of infertile men after puberty remained “all in all not very successful.”58 By 1960, only ten per cent of the roughly 300,000 men with fertility disturbances responded to therapy.59 Of the few options available,60 which were surgery to remove obstruction and later the use of steroids to stimulate sperm production, the controversial “therapy” of insemination will serve here as an illustrative example of the interrelation of politics, knowledge, and the body. Members of the medical profession conducted artificial insemination throughout the twentieth century, albeit rarely. Advancing their own expertise and responding to childless couples’ stress, doctors remained confined by traditional ideas of marriage and conception and thus they  uneasily engaged with homological insemination, which used the husband’s sperm.61 The second type of insemination, called heterological insemination, involved the use of donor sperm and thus did not cure infertile men but allowed them to become fathers nevertheless. Heterological insemination was rejected by the majority of physicians in  the 1950s for a number of reasons: it was believed to be a purely ­purpose-driven treatment without natural foundation, it was deemed to be unethical and morally unacceptable, and it was believed to bypass medical professional guidelines that provided for homological insemination only.62 Heterological insemination was not forbidden, but a draft bill existed to place it under punishable law, and the conservative Bundesärztekammer (German Medical Association) supported homological insemination only, in part because of questions of biological-­ social fatherhood. With a close eye on the potential sociocultural implications for the children conceived, the Deutscher Ärztinnenbund (German Medical Women’s Association) advocated a stronger stance by supporting a judicial ban on hetereological insemination. Yet inseminations, specifically the contested heterological version, were conducted anyway, propelled by the demands of infertile couples who had had no luck with intrauterine insemination using the husband’s sperm.63 Sources suggest that by 1954 around 1,000 children had been born by heterological insemination; by 1967 this figure had

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risen to roughly 2,300, illustrating that official normative mores did not always have a stronghold on individual doctor–patient relationships.64 Those in favour of heterological insemination at that time were driven not only by its beneficial, “therapeutic” outcome for male infertility and the strain experienced by infertile couples but also by eugenic considerations. A eugenic jargon crept into the medical debates about artificial insemination that gained momentum in post-war Germany and had particular currency among some physicians who continued their medical and research practices despite their former collaboration with the Nazis. The use of heterological insemination, they argued, would strengthen the “natural selection” of pathogenic sperm and lower the number of weak genes,65 reducing the fetal harm that would otherwise occur from sperm originating in men’s dysfunctional reproductive bodies.66 Here, then, older discussions of population politics and eugenics made their way into the debate at the juncture of pro- and anti-natalist theories. Rudolf Doepfmer, for example, felt himself stuck between two physicians’ tasks: to prohibit conception in cases of genetically diseased family members67 and to succeed in helping couples to conceive. This conflict remained as late as 1983, after the first in vitro fertilization treatments had been conducted in Germany, when physicians questioned the use of sperm from men with certain medically defined conditions that reduced their sperm quality, such as azoospermia (lack of live or failure to form spermatozoa in the semen) or testis hypoplasia (incomplete development or underdevelopment of the testis).68 Through the “scientification of the social”69 doctors increasingly defined, with the technological means at hand, male infertility as a disease, thereby placing it within the traditional parameters of medical responsibility.

Disciplining Unhealthy Male Bodies In the context of infertility and reproduction discourses in the post-war decades, the ideal of the normative, that is, healthy and thus “stable” male body (as opposed to the ideal of a malleable female body), was contested.70 It became subject to a diagnosis of infertility in laboratories and clinical settings and disciplined to conform to the technological requirements of the medical establishment, as I will discuss below. The (medical) debate over what made the male body normative confirms Foucault’s concept of the political technologies of the body as they relate to the “micro-physics of power” situated between the reproductive

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dispositif – which includes family politics, cultural ideals, and norms of fatherhood – medical disciplines, and “the bodies themselves.”71 Increasingly, the male body was measured by its reproductive capacity, and infertility was identified by diagnostic taxonomies and related medical classification. The first of these required a definition of the healthy, that is, the stable body. Early medical research focused on volume and shape of sperm, but from the 1950s onwards sperm function was scrutinized, with an ever-growing refinement of categories, and from there attention was extended to organs such as the testes. This led to new practices in the way in which sperm was gathered, as well as new perspectives on bodily features themselves, such as sperm, the testes, and the endocrinological system. Doctors were aware of the volatile nature of men’s ejaculate and spermatogenesis (process of formation of spermatozoa); they knew that ­spermiograms needed to be read individually and by themselves were not reliable.72 By 1964, international medical classification standards still did not exist, in part because the measurements taken were inexact and in part because of the difficulty of working with men through all the needed examinations. As a result, clinicians made significant corrections to the number of sperm per unit of semen deemed necessary for male fertility over the years. They were determined to achieve this in part by finding a man’s “real” sperm. Some suggested this could be achieved only by analyzing multiple ejaculates, with a time lag between episodes of masturbation of less than three hours, since some men displayed signs of what was called ejaculatum secundum melius.73 Requiring multiple ejaculates could serve, some doctors argued, as a disciplinary measure to expose those men who declined fatherhood claims on the part of the mother: the argument was that those men who declined to produce a second ejaculate that might show their intact reproductive capacity did so because they intended to hide their fatherhood.74 To obtain workable ejaculates for a spermiogram, men were required to abstain from sex for either five to six or ten days before providing a sample, depending on the geographical area of the clinic; patient records reveal that men often did not adhere to these periods of abstinence.75 Ensuing debates about getting sperm through masturbation for diagnosis were not confined to the materiality and demands of doing so but also addressed the concomitant social and cultural issues involved. Despite general debate in the 1950s about the morality of masturbation,76 which was once cast as counterproductive to good health, that concern was overridden by scientific requirements to obtain the “proper” ejaculate.77

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The hegemonic ideal of virile, self-sufficient manhood78 was threatened by men whose bodies were reproductively impaired, at least if we follow physicians’ testimony. For example, a number of physicians noted that their patients were defined by a patriarchal system that led them to resent having a medical examination and acknowledging infertility. Confusing potency with fertility, the stigma of the condition of infertility led them to question their self-identity and conception of the male role.79 It resulted in the lack of an active patient role in finding the  “cause” of infertility. The case files from the andrology clinic in Hamburg, for example, suggest that in the majority of cases, a man was referred by his wife’s gynecologist, that only a minority came because of their own concern, and that most men attending were married. Only a few of the men concerned about their fertility were single. One more prominent doctor suggested that the solution to this social and cultural concern could be resolved by injecting donor sperm into the seminal vesicle of the husband; whether this suggestion was actually followed through is not recorded.80 Yet, the technological processes in part shaped the discourse about hegemonic ideals of men when doctors apparently used “semen cocktails” drawn from different donors in ­heterological insemination practices. Here, protracted insemination practices taking place over several days required them to shift donors, thereby upsetting the primary wish of most couples that the donor should roughly match the husband’s features.81 The emphasis on the idea of the normative male, that is, healthy, was prevalent within the infertility discourse: even though andrologists were adamant that fertilization could take place without a normal spermiogenesis, any aspect of the patient constructed as deviant was singled out. Files at the clinic in Hamburg, for example, alluded to “abnormal personality development,” meaning homosexuality or hypogonadism.82 Redefined scales were used meticulously to note the correspondence of the patient to a normative body in terms of height, amount of pubic hair, size of testicles, and size of male breasts, all recorded on diagnostic sheets. With such an emphasis placed on the normative male body, physicians were particularly puzzled by those men diagnosed to be infertile who in essence looked like “nearly normal men”83 and whose genitals matched normative criteria.84 It is within this line of thought that new guidelines on the traditional medical practice of testis palpation were instituted by Schirren. Rather than using the purportedly unscientific palpation techniques of manipulation using the doctor’s own hands, a measurement device for testes,

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called an anorchidometer, was favoured using the specified criteria of “normal” testis volume.85 The outcome of these practices was ultimately disappointing and did not standardize male bodies. Male bodies, or at least their reproductive organs, actually appeared to be ever more vulnerable and unstable, not only because of external forces such as workrelated factors, atomic factories, pharmaceutical and hormone therapy, and iatrogenically induced effects on spermatogenesis, but also because of internal factors such as testis dystopia (displaced testis), orchitis (inflammation of the testicle), or cryptorchidism (undescended testicle).86 Above all it was diagnostics, technologies, and medical practices introduced by doctors themselves that further revealed and at the same time, in a Foucauldian sense, created unstable male bodies.

Conclusion This chapter has outlined how in the 1950s and 1960s, after the formal end of pro-natalist Nazi politics and before the official establishment of andrology and the introduction of in vitro fertilization and later intracytospermatic insemination treatment to the wider public, the male reproductive body was subjected to a medical gaze and made both an object of medical scrutiny and a locus of knowledge production.87 The male reproductive body and the issue of infertility, while part of the research practices of different medical fields, unfolded as a dispositif of male reproduction during the period under investigation. The disciplining of male reproductive bodies from a variety of medical practices in the post-war decades was partly due to the fact that this process was used to strengthen the speciality status of a number of medical subdisciplines at the time of the (re)construction of the field of reproductive medicine after the war. Bringing men’s reproductive health into focus was also a technical matter, involving technological advances in cryoconservation and knowledge of female ovulation. In addition, it was stirred by a contextualized sense of the vulnerability of men’s status – and by extension their bodies – exposed to post-war changes in fatherhood status, eugenic arguments, and the fact of a wartorn society. Why, however, despite increasing medical research on men’s bodies and fluids, judicial changes to men’s status and role as fathers, and the extent to which these were tied up with population politics, did the issue of male reproduction never become mainstream as was the case with female reproduction, and acknowledged by the wider public? There is  no simple answer to this question, but there are a number of

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possibilities. Knowledge production was spread unevenly among the scientific fields competing for authority on men’s infertility. The growing discussion about men’s infertility also coincided with much more open, indeed fierce, public debate about contraception stirred by the introduction of the contraceptive pill in 1961 and tied up with women’s liberation from reproductive processes and changes in sexual habits and society, which became a laboratory for gender politics in the 1960s.88 Thus, the drop in birth rates by the late 1960s was less discussed in terms of infertility than in terms of contraception: men’s reproductive pathologies were examined away from the public eye. When the issue of infertility finally did come into the open when the first baby produced by in vitro fertilization was born, central to the public debate was the female, not the male, body. Even the greater consequences of technological advances that separated biological and social fatherhood, and that increasingly filled the patient case files and courtrooms, excluded the matter yet again from wider public notice.89 The gendered health discourse on reproduction has obscured men’s reproductive body just as the early years of AIDS discourse obscured the possibility of it in women (see chapter 8 by Natalie Gravelle). Male infertility, once determined simply by a lack of offspring, came to be established as a disease increasingly within the realm of medical ­responsibility. The medical and sociopolitical discussions about unhealthy reproductive men’s bodies, which were so characteristic of late-twentieth-century popular debates, and specifically debates on men’s health, occurred much earlier than has been so far detailed. Uncovering the history of male infertility treatment and the specialities that grew up around it highlights the medicalization of men’s ­bodies that went along with it in the quest to find the healthy reproductive body.

Acknowledgments I thank the editors, Tracy Penny Light, Barbara Brookes, and Wendy Mitchenson, for the initial invitation to join their book project, and I thank them and the anonymous referees for their insightful comments. Earlier drafts of this chapter were presented at the “Verletzbarkeiten – geschlechterwissenschaftliche Perspektiven” of the Gender Studies Association conference in Munich in 2011, at the D F G-sponsored network “Economies of Reproduction” in Braunschweig in 2011, and at the “Infertility in History, Science and Culture” conference in Edinburgh

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in 2013. I thank the participants of these conferences and the network members for their stimulating input.

notes   1  Inhorn and van Balen, Infertility Around the Globe, 19. Parts of the chapter were published earlier in Kampf, “Tales of Healthy Men.” This chapter is a reconceptualized, substantially revised and enhanced version of the paper.   2  See, for example, Martin, The Woman in the Body; Clarke and Ragone, Reproducing Reproduction; Clarke, Disciplining Reproduction; Saetnan, Oudshoorn, and Kirejczyk, Bodies of Technology. For a good overview and discussion of the epistemology of the body within gender history, see Canning, “The Body as Method,” 168–238.  3 Planert, Der dreifache Körper des Volkes, 567.   4  Scholars have recently argued the case for “men’s reproductive marginalization,” questioning whether there is such a disassociation of men from the processes of reproduction. See Inhorn, TjørnhøjThomsen, Goldberg, and la Cour Mosegaard, Reconceiving the Second Sex, 1.   5  The exception to this pattern is Wöllmann, “Andrologie und Macht”; Kampf, “Tales of healthy men”; and Hofer, “Der Frauenarzt und die Sterilität des Mannes.” Men’s reproduction has so far been researched mainly from a sociological and anthropological perspective focused on the late twentieth century: see Oudshoorn, The Male Pill; Daniels and Golden, Procreative Compounds; Moore, “Extracting Men from Semen”; Greil, “Infertile bodies.” The history of male infertility in modern Germany is still very much in the making: on insemination and sperm in the 1900s, see Benninghaus, “Great Expectations,” and “Beyond Constructivism? Gender, Medicine and the Early History of Sperm Analysis, Germany 1870–1900,” Gender & History 24, 3 (2012): 647–76, and Florence Vienne, “Vom Samentier zur Samenzelle: die Neudeutung der Zeugung im 19. Jahrhundert” Berichte zur Wissenschaftsgeschichte 32, 3, 215–29; on Weimar biopolitics, see Planert, Der dreifache Körper des Volkes: Sexualität, Biopolitik und die Wissenschaften vom Leben; and on Nazi biopolitics, see Vienne, “Der Mann als Medizinisches Wissensobjekt: Ein Blinder Fleck in der Wissenschaftsgeschichte.” These studies have helped to outline the wider terrain.   6  The procedure works by extrapolating a single sperm selected for insemination as part of the in vitro fertilization treatment.   7  Foucault, “The Confession of the Flesh.”

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 8 Clarke, Disciplining Reproduction. Clarke has focused on the emergence of the successful disciplining of American reproductive medicine, a medical praxis that was not as cohesive in the German context.   9  Foucault, “Nietzsche, Geneaology and History,” here: 78, 80, 82–3; Foucault, The History of Sexuality. An Introduction, 151–2. 10 Connell, Masculinities; Petersen, Unmasking the Masculine; Inhorn, TjørnhøjThomsen, Goldberg, and la Cour Mosegaard, Reconceiving the Second Sex, 5. 11  The studies are housed in the Staatsarchiv Hamburg (hereafter S A H ). This chapter draws upon the extant patient files of this department from 1957 to 1972. 12  There is still no comprehensive study of the history of German medicine after the Second World War, although there are a number of important localized studies on the reconstitution of the German medical profession at universities in the post-war decades and on details of physicians who continued active practice and sympathized with Nazi politics or jargon. See, for example, Anne Cottebrune, “Eugenische Konzepte in der westdeuscthen Humangenetik, 1945–1980,” Journal of Modern European History 10 (2012): 500–17; Anna Valentina Lahn, “Syphilis im Hamburg der Nachkriegszeit,” Diss. med., University of Hamburg, 2009; Öhler-Klein and Roelcke, Die Medizinische Fakultät der Universität Gießen im Nationalsozialismus und in der Nachkriegszeit: Personen und Institutionen, Umbrüche und Kontinuitäten. (Stuttgart: Franz Steiner, 2007). 13  By 1959, the male infertile body was common medical knowledge, as ­evidenced by the entry of male infertility directly under the heading ­sterility in the major medical dictionary Pschyrembel. Pschyrembel Klinisches Wörterbuch. (Berlin: de Gryter, 1959), 837. 14  H.W.Vasterling, “Zur Erkennung und Behandlung der Männlichen Fertilitätsstörungen,” Deutsche Medizinische Wochenschrift 38 (1958): 1648–51, here: 1648; W. Kiessling, “Fortschritte und Aufgaben der Andrologie,” Deutsche Medizinische Wochenschrift 84 (1959): 516–20, here: 517. On the early history of infertility treament see Benninghaus, “Great Expectations.” 15  Despite the close collaboration of a number of gynecologists in fascist biopolitics, soon after the war, gynecology gained its professional footing with the first conference of the German Association for Gynaecology, convened in 1949. 16  He was director of the gynecological department at the University of Bonn and performed forced sterilizations and possibly abortions under the Nazi regime. See Forsbach, Die Medizinische Fakultät der Universität Bonn im “Dritten Reich,” 612.

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17  Richard Fikentscher, “Eröffnungsansprachen,” in ders. (Hg.). Beiträge zur Fertilität und Sterilität. (Beilageheft zur Zeitschrift für Geburtshilfe 157) (Stuttgart: Enke, 1961), here: 2. 18  H.R. Kühnelt, “Möglichkeiten und Grenzen der Sterilitätsbehandlung,” Beitrage zur Fertilität und Sterilität. Beilageheft zur Zeitschrift für Geburtshilfe 152 (1959): 32; R. Doepfmer and R. Ulrich, “Die forensische und versicherungsrechtliche Beurteilung der impotentia coeundi,” Berufsdermatosen 14, 3 (1966): 113. Whether this empathy was further underlined by the fact that there were many more male than female gynecologists in the post-war decades (by 1956, 9.7 per cent of gynecologists were women and by 1919, 17 per cent were women) has to be left open for discussion. Statistics were compiled from Statistisches Bundesamt www.gbe-bund.de (accessed 17 January 2013) and Eva Brinkschulte, Weibliche Ärzte: Die Durchsetzung des Berufsbildes in Deutschland (Edition Hentrich Druck, 1994). 19  G.K. Döring, “Über die Verbesserung der Konzeptionschancen bei Oligospermie mit Hilfe der Portiokappe,” Beitrage zur Fertilität und Sterilität. Beilageheft zur Zeitschrift für Geburtshilfe 164 (1964), 32. Originally the cap was introduced as a contraceptive barrier. Sources indicate that gynecologists did not often apply portio caps. S A H 352-83 Abl. Andrologie 2004/04, Ordner 1–16. 20  H.H. Knaus, “Eröffnungsansprachen,” in Richard Fikentscher (Hg.). Beiträge zur Fertilität und Sterilität. (Beilageheft zur Zeitschrift für Geburtshilfe 157) (Stuttgart: Enke, 1961), here: 183. The relationship between gynecological surgery and knowledge of human insemination is described in Moscucci, The Science of Woman. On the history of the development of a ­cyclical concept of menstruation, see Martina Schlünder, “Die Herren der Regel / n? Gynäkologen und der Menstruationskalender als Regulierungsinstrument der weiblichen Natur,“ in C. Borck, V. Hess, and H. Schmidgen, Maß und Eigensinn, Versuche im Anschluss an Georges Canguilhem (München: Fink, 2005), 157–95. 21  R.M. Bohnstedt, “Fertilitätstörungen bei Varikocelen und nach Hodendystrophien und Leistenbruchoperationen,” in Richard Fikentscher (Hg.). Beiträge zur Fertilität und Sterilität. (Beilageheft zur Zeitschrift für Geburtshilfe 157) (Stuttgart: Enke, 1961), 156–61. Before the onset of ­sulphonamides, thousands of men per year were considered infertile because of untreated infections with gonorrhoea. A classic general history of sexually transmitted diseases in Germany can be found in Lutz Sauerteig, Krankheit, Sexualität, Gesellschaft: Geschlechtskrankheiten und Gesundheitspolitik in Deutschland im 19. und frühen 20. Jahrhundert (Stuttgart: Franz Steiner, 1999).

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22  Rudolf Doepfmer, “Die Bedeutung der Infektionskrankheiten für die männliche Infertilität,” in Richard Fikentscher (Hg.). Beiträge zur Fertilität und Sterilität. (Beilageheft zur Zeitschrift für Geburtshilfe 152) (Stuttgart: Enke, 1959), 43–6, here: 43. 23  Ibid., 46. As a testimony to the importance of dermatology in this realm was also the acknowledgement of funding received by the German Research Foundation for research on human sperm analysis in the late 1950s. 24  In contrast to the Anglo-American realm, where andrology was a subdis­ cipline of urology, in Germany most andrology clinics emerged out of ­dermatology departments. By 1891, US physicians had already tried unsuccessfully to create the discipline of andrology; in Britain, andrology clinics were created in the 1920s. 25  Carl Schirren, “25 Jahre Andrologie. Betrachtungen zur Jubiläumstagung der Deutschen Gesellschaft zum Studium der Fertilität und Sterilität,” in Carl Schirren, Kurt Semm (Hrsg.), Kongreßbericht 1983: 25 Jahre Deutsche Gesellschaft zum Studium der Fertilität und Sterilität (Berlin, 1984), 41–8, here: 44–5. 26  On polyspermy in bulls, see Rudolf Doepfmer, “Die klinische Bedeutung der absoluten, der partiellen (einseitigen) und der relativen PSolyspermie für die Pathogenese der männlichen Infertilität,” Archiv für klinische und ­experimentelle Dermatologie 215 (1962): 246–60. Reasons for the change from agricultural to human reproductive technologies can be found in Sarah Wilmot, “Between the Farm and the Clinic: Agriculture and Reproductive Technology in the Twentieth Century,” Studies in History and Philosophy of Science Part C 38, 2 (2007): 303–15. Advances in reproductive technology, in particular the capacity to preserve sperm with glycerol, were achieved by 1949 in the United Kingdom and the United States. On spermatozoa research during the Nazi regime, see Vienne “Der Mann als Medizinisches Wissensobjekt: Ein Blinder Fleck in der Wissenschaftsgeschichte,” 226. On the relation between agricultural and human sperm research in the aftermath of Nazi politics, see Anna Frederike Heinitz and Rickmer Roscher, “The Making of German Sperm. Überlegungen zum Zusammenhang von Spermakonservierung, Männlichkeiten und Nationalsozialismus,” Berliner Blätter, Sonderheft 51 (2010): 29–67. The legacy of Nazi eugenic politics meant that semen banks were established much later in Germany than elsewhere in the West and, initially at least, remained in the hands of individual medical practitioners. One of the first was established in 1981 in Essen. By 1979, cryoconservation of human sperm in Germany was still experimental. H.G. Mutke, “Probleme bei der Tiefkühlkonservierung von Humasperma,”

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in C. Schirren, L. Mettler, and K. Semm (Hrsg.), Kongreßbericht Kiel. Fortschritte der Fertilitätsforschung 8 (Kiel, 1979), 256–8. 27  Gerald L. Moench and Helen Holt, “Sperm morphology in relation to ­fertility,” American Journal of Obstetrics & Gynaecology 22 (1931): 199–210; Hermann Stieve, “‘Untersuchungen über die Wechselbeziehungen zwischen Gesamtkörper und Keimdrüsen. III. Beobachtungen an menschlichen Hoden,” Zeitschrift für mikro.-anatomische Forschung 1 (1925): 496–512. 28  On the change in methodology, see Carl Schirren, “Die Bedeutung biochemischer Untersuchungen für die moderne Fertilitätsdiagnostik beim Manne,” in Richard Fikentscher (Hg.) Beiträge zur Fertilität und Sterilität. (Beilageheft zur Zeitschrift für Geburtshilfe 157) (Stuttgart: Enke, 1961), 166–8, here: 166–7. For a discussion on the relation between gynecology and ­andrology in the 1950s, see also Hofer, “Der Frauenarzt und die Sterilität des Mannes.” 29  These clinics were predominantly administered by physicians coming from dermatology, except for two cases from the disciplines of gynecology (H.W. Vasterling, Göttingen) and endocrinology (H. Nowakowski, Freiburg). A specific discussion on the situation in Eastern Germany is beyond the scope of this paper but part of ongoing research. 30  The establishment of andrology as a profession was secured only in 1976, by the founding of the German Society of Andrology and with the support of its journal, Andrologia. 31  Owing to the specific focus of sexology research in the 1950s and early 1960s, directed by Hans Giese, and despite the founding of the world’s first sexology association in 1950, the German Association of Sexology, major collaborations on male infertility did not commence on a broad scale before the 1970s. Sigusch, Geschichte der Sexualwissenschaft, 364–87, 393–429. However, doctors argued as early as the 1950s that physicians should advise on how to reduce infertility caused by genital infection; see August Mayer, “Bemerkungen zum Kampf gegen die Unfruchtbarkeit,” in Richard Fikentscher (Hg.) Beiträge zur Fertilität und Sterilität (Beilageheft zur Zeitschrift für Geburtshilfe 152) (Stuttgart: Enke, 1959), 59–68, here: 68. They also called for better sex education for the population as a whole because men were attending with testis dystopia, resulting in infertility, without ever having been checked by their parents. Rudolf Doepfmer, “Prophylaktische Maßnahmen zur Verhinderung der männlichen Infertilität” in Richard Fikentscher (Hg.) Beiträge zur Fertilität und Sterilität (Beilageheft zur Zeitschrift für Geburtshilfe 162) (Stuttgart: Enke, 1964), 13–17, here: 14. 32  Hans Boeminghaus and Herbert Klosterhalfen, “Zur Fertilität des Mannes,” Zeitschrift für Urologie 51, 5 (1958): 249–65, here: 250.

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33  The procedure was introduced in 1939 by the American urologist Robert Hotchkiss. 34  This was still preliminary, as the focus in the 1950s with regard to the ­development of sex hormones remained centred on the female body. See Oudshoorn, The Male Pill. 35  Such as inflammation of the testis, undescended testis, or damage to the cellular tissue of the testis. 36  A chair in urology was not opened again at a German university before 1952. A classic medical textbook was Robert Bachrach, Victor Blum, and Franz Colmers, Spezielle Urologie Tl 3., Erkrankungen der Harnleiter, d. Blase, Harnröhre, Samenblase, Prostata, d. Hodens u. Samenstranges u. d. Scheidenhäute (Berlin: Springer, 1928), which set out treatment for misshapen genital organs and the reproductive problems of men. Research and treatment with testis implantations and sexual neurasthenia are detailed in Chandak Sengoopta, The Most Secret Quintessence of Life: Sex, Glands, and Hormones, 1850–1950 (Chicago: Chicago University Press, 2006); Heiko Stoff, Ewige Jugend. Konzepte der Verjüngung vom späten neunzehnten Jahrhundert bis ins Dritte Reich (Köln: Böhlau, 2004). 37  R. Übelhör, “Entwicklungsbedingte Störungen der männlichen Fertilität,” in Richard Fikentscher (Hg.) Beiträge zur Fertilität und Sterilität (Beilageheft zur Zeitschrift für Geburtshilfe 162) (Stuttgart: Enke, 1964), 3–4. 38  D. Voelter and K. Oswald, “Operative Therapie Männlicher Fertilitätsstörungen,” Deutsche Medizinische Wochenschrift 95 (1970): 1065. 39  Robert Proctor, “Nazi Science and Nazi Medical Ethics: Some Myths and Misconceptions,” Perspectives in Biology and Medicine 43, 3 (2000):335–46. 40  Richard Fikentscher, “Eröffnungsansprache,” in Richard Fikentscher (Hg.) Beiträge zur Fertilität und Sterilität (Beilageheft zur Zeitschrift für Geburtshilfe 152) (Stuttgart: Enke, 1959), 1–5, here: 3–4. 41  Quoted in Moeller, “The Homosexual Man is a ‘Man,’” 412. 42  W. Schultz, “Operative Behandlungen der Männlichen Sterilität,” Deutsche Medizinische Wochenschrift 19 (1949): 611–12. These requests were also voiced by some general practitioners who sought answers to the problem of male ­infertility, such as those published in the Deutsche Medizinische Wochenschrift (d m w , “German Medical Weekly Journal”) between 1952 and 1964 on a wide range of pertinent issues, including sterility, impotence, and insemination; see Karlheinz Kohlberg, “Die Beurteilung der Zeugungsfähigkeit des Mannes,” dmw 78 (1953): 1666, 1675–76; Karlheinz Kohlberg, “Fragen an die Praxis,” dmw 30 (1956): 1207. The largely unexamined history of reversing forced (and voluntary) sterilization of men awaits future research. 43  Cf. Biess, Homecomings.

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44  For early discussions of the state of population rates and eugenics, see Heinemann, What Difference Does a Husband Make; Kuller, “Familienpolitik in der Bundesrepublik Deutschland 1949–1975.” 45  For a thorough discussion of the nationalist definition of Volksgesundheit (“health of the population”), see Michael H. Kater, “Volksgesundheit. Ein biopolitischer Begriff und seine Anwendung,” in Lehmann, Hartmut / Oexle, and Otto Gerhard (Hrsg.) Nationalsozialismus in den Kulturwissenschaften Bd. 2 (Göttingen, 2004), 101–14. 46  The decline of birth rates per year accelerated after 1964, falling to its lowest rates in 1977 since 1950. Rolf Kaiser, “Bevölkerungsentwicklung, Familienplanung, natürliche- und hormonelle Kontrazeption,” in Rolf Kaiser and Gerhard F.b. Schumacher, Menschliche Fortpflanzung. Fertilität – Sterilität- Kontrazeption (Stuttgart: Thieme, 1981), 317. Despite its “family politics” approach, the ministry still retained the distinct rhetoric of an interventionalist and pro-natalist state. On the re-­ establishment of traditional gender roles during the Adenauer era, see Johanna Meyer-Lenz, “Zum Plan einer Entdeckungsreise in den Geschlechterdiskurs der Nachkriegszeit mit dem Instrument der Oral History,” in ders., (Hrsg.) Die Ordnung des Paares ist unbehaglich. Irritationen am und im Geschlechterdiskurs nach 1945 (Hamburg: L I T Verlag, 2000), 43–5. 47  Moeller, “The Homosexual Man is a ‘Man,’” 424, 406. See also Hans Giese, Mensch, Geschlecht, Gesellschaft: Das Geschlechtsleben unserer Zeit gemeinverständlich dargestellt, 2nd ed. (Baden-Baden, 1961). For a critical discussion of the existence of a “normal family,” see Rene König, “Family and Authority, the German Father 1955,” British Sociological Review 5 (1957), 107–27. Compare with Moeller, Protecting Motherhood. Women and the Family in the Politics of Postwar West Germany. 48 Heineman, What Difference Does a Husband Make?, 119; see also Moeller, Homecomings, 97–125; Plötz, “Heimkehrer, die natürliche Ordnung und vollständige Familien.” On the ideal role of the father in the family, see also Kuller, “Familienpolitik in der Bundesrepublik Deutschland 1949–1975: Charakteristika und Phasen im Überblick,” 44–5. 49  A critical reading of the continuities and discontinuities of traditional conservative political thought can be found in Heinemann, 2006, 122–3; Drinck, Vatertheorien, 21–36; Niehuss, “Kontinuität und Wandel der Familie in den fünfziger Jahren,” 316–34. 50  “Unzucht unter Maennern” §175 StGB. 51 Drinck, Vatertheorien, 193–6.

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52  This tapped into older ideas stemming from experiential research in the 1920s, the war experience of incarcerated men in Nazi concentration camps – which led to psychological or physical disabilities and the development of azoospermy (lack of spermatogenesis) – and the health of ­returning veterans. On the psychological dimension, see G. Schmidt, “Partielle Impotenz als Kriegsschadensfolge,” unpublished doctoral dissertation (Technische Universität München, 1975), 94. Hans Schürmann, “Männliche Fertilitätsstörungen u. psychische Einflüße auf die Spermiogenese,” Medizinische Klinik 43, 13 (1948), 366–8; Kühnelt, “Möglichkeiten und Grenzen der Sterilitätsbehandlung,” 31; Mayer, “Bemerkungen zum Kampf gegen die Unfruchtbarkeit,” 64–5. 53  These issues were correlated with risk factor models and the increasingly poor health of the business / managerial type of man. See, for example, Madaràsz-Lebenhagen and Kampf, “Prävention in den beiden deutschen Staaten, 1949–2000.” 54  Kiessling, “Fortschritte und Aufgaben der Andrologie,” 517. Particularly strongly supported by Kühnelt, “Möglichkeiten und Grenzen der Sterilitätsbehandlung”; Mayer, “Bemerkungen zum Kampf gegen die Unfruchtbarkeit,” 65. On the change of body type, see Frevert, “Umbruch der Geschlechterverhältnisse? Die 60er Jahre als geschlechterpolitischer Experimentierraum,” 656. 55  Kühnelt, “Möglichkeiten und Grenzen der Sterilitätsbehandlung,” 31. 56  Rudolf Doepfmer, “Die männliche Fertilität bei Jugendlichen und Greisen,” Deutsche Medizinische Wochenschrift 11 (1960): 427. The ruling overturned an older decree that did not see the mental strain of stress as inducing infertility, which in turn was believed to reduce job success. The argument that stress effected male infertility and had a negative impact upon job success changed in later years from concern with population and the negative effect it had on economics to a more internal, gendered characteristic: doctors believed that men could (re)gain fertility simply by attending an andrological examination. G. Veltman, “Therapie Männlicher Fertilitätsstörungen,” dmw 95, 37 (1970): 1891–92. 57  Pschyrembel 1959, 837. 58  Boeminghaus and Klosterhalfen, “Zur Fertilität des Mannes,” 260. 59  W. Nikolowksi, “Männliche Fertilitätsstörungen als Ursache der sterilen Ehe,” Münchener Medizinische Wochenschrift 109 (1967): 913–18. 60  The main options were either surgical procedures for varicocele, introduced by the 1950s, or the use of androgenic steroids, which could, paradoxically, produce infertility as a side effect.

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61  In the early twentieth century, gynecologists would carry out artificial insemination only if the infertile husbands themselves delivered the donor sperm to the doctors’ rooms, revealing the fear of claims of adultery. Hommel, “Hermann Rohleder (1866–1934) und die Anfänge der künstlichen Befruchtung in Deutschland,” 143–4. This type of insemination was first conducted in 1884 in America, and in Germany in 1912, as part of sterility treatment, see Benninghaus, “Great Expectations – German Debates about Artificial Insemination in Humans around 1912.” 62  Kohlberg, “Fragen an die Praxis,” 1207; August Mayer, “Die heterologe künstliche Insemination in psychologisch-ethischer Sicht,” Ärzte Magazin 11 (1959): 341–5; Katzorke, “Entstehung und Entwicklung der Spendersamenbehandlung,” 17. 63  W. Kupka, “Erfahrungen mit der heterologen Insemination in einer gynäkologischen Praxis 1974–1983,” in C. Schirren and K. Semm (Hrsg.), Kongreßbericht Rothenburg o.d.T. 1983. Fortschritte in der Fertilitätsforschung 12 (Berlin: Grosse Verlag, 1983), 210–7. 64  Spann, Ärztliche Rechts- und Standeskunde, (München: Lehmanns, 1962), 294–5; Katzorke, “Entstehung und Entwicklung der Spendersamenbehandlung in Deutschland,” 17. It took until the 1970s for heterological insemination to be officially tolerated, in part in response to the positive results of the procedure in comparison with homological insemination. Döring, “Über die Verbesserung der Konzeptionschancen bei Oligospermie mit Hilfe der Portiokappe,” 32–4. 65  Kühnelt, “Möglichkeiten und Grenzen der Sterilitätsbehandlung,” 34; Boeminghaus and Klosterhalfen, “Zur Fertilität des Mannes,” 263. 66  Boeminghaus and Klosterhalfen, “Zur Fertilität des Mannes,” 263. Studies were increasingly being conducted into male-mediated harm on fetuses, for example, Rudolf Doepfmer, “Aktuelle Fragen über Störungen der männlichen Fertilität” in Richard Fikentscher (Hg.) Beiträge zur Fertilität und Sterilität (Beilageheft zur Zeitschrift für Geburtshilfe 155) (Stuttgart: Enke, 1960), here: 9; Raetz, “Beziehungen zwischen Polyspermie und Fehlgeburt.” 67  Official genetic counselling did not commence before the 1970s. 68  D. Krause, “Verantwortung für Reproduktionsmanipulation,” in C. Schirren, L. Mettler, and K. Semm (Hrsg.), Kongreßbericht Rothenburg o.d.T. 1983. Fortschritte in der Fertilitätsforschung 12 (Berlin: Grosse Verlag, 1983), 55. 69  Silies, “Verhütung als Mittel gegen Bevölkerungswachstum, 247. 70  This aspect is further discussed in Kampf, “Tales of Healthy Men,“ 24–9. 71 Foucault, Discipline and Punish., 25–6.

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72  Physicians were also aware of those cases of men with normospermia who produced children only years later, or those who were diagnosed as being subfertile and who still became fathers. 73  H. Bauer, “Wann ist die Untersuchung eines Zweitejakulates,” (Karenz bis 3 Stunden) angezeigt?” Richard Fikentscher (Hg.) Beiträge zur Fertilität und Sterilität. (Beilageheft zur Zeitschrift für Geburtshilfe 168) (Stuttgart: Enke, 1968), 69–79, here: 69. Ejaculatum secundum melius was a clinical situation in which the second ejaculate probe revealed a normal spermiogenesis (or at least a better outcome than the first). 74  Ibid., 78. 75  S A H , 352-83 Ordner 1 1957. Carl Schirren later conceded that five to six days of sexual abstinence was unnecessary to obtain sperm of high enough quality for examination. In 1960, Doepfmer recommended a ­hiatus of three to four days. Rudolf Doepfmer, “Aktuelle Fragen über Störungen der männlichen Fertilität,” in Richard Fikentscher (Hg.) Beiträge zur Fertilität und Sterilität (Beilageheft zur Zeitschrift für Geburtshilfe 152) (Stuttgart: Enke, 1960), here: 9. 76  Specifically through the influence of Catholic physicians who reminded attendees of the urology congress in 1953 of the papal prohibition against using masturbation to obtain sperm without cohabitation. By contrast, ­judicial law handbooks advised that only freshly masturbated sperm could be useful and, if necessary, garnered by expressing the semen, Albert Ponsold, Lehrbuch der gerichtlichen Medizin (Stuttgart: Thieme, 1950), 430. 77  S A H , 352-83 Ordner 4 1965-66. Archival notes reveal that men were at times helped by prescriptions to produce a workable ejaculate. Such a procedure was critiqued by some physicians as producing unscientific results. 78 Connell, Masculinities, 86–71. See also Kimmel, Hearn, and Connell, Handbook of Studies on Men & Masculinities. 79  Franz Wittenbeck, Kinderlosigkeit in der Ehe (Stuttgart: Enke, 1955), 2. This behaviour did not seem to change over time: Doepfmer, “Prophylaktische Maßnahmen zur Verhinderung der männlichen Infertilität,” 15; Katrin Schirren, “Das andrologische Patientengut des Dermatologen Dr. med. C.G. Schirren aus den Jahren 1953–1969,” 12. Paul Lauritzen has pointed out that when culture “defines virility so completely in phallocentric terms, infertility can also threaten male identity, for infertility is often confused with impotence.” Lauritzen, “What Price Parenthood?,” 39, 41. 80  Wolfgang Spann, Ärztliche Rechts- und Standeskunde, (München: J.F. Lehmanns Verlag, 1962), 296. 81  Mutke, “Probleme bei der Tiefkühlkonservierung von Humasperma,” 256. The “fictions” made out of such procedures are interesting but beyond the scope of this paper.

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82  S A H , 352-83; Ordner 4 1965-66. Patient 103; S A H , 352-83 Ordner 1 1957-1962. Patient 76. 83  W. Zehetgruber, “Ursachen der männlichen Fertilitätsstörungen,”Zeitschrift für Urologie 50 (1957): 511. 84  S A H , 352-83 Ordner 1 1957-1962. Patient 71. 85  Katrin Schirren, “Das andrologische Patientengut des Dermatologen Dr. med. C.G. Schirren aus den Jahren 1953–1969,” 8. 86  On external factors leading to decreasing spermiograms, see H.R. Kühnelt, “Möglichkeiten und Grenzen der Sterilitätsbehandlung”; W. Nikolowski, “Diskussion,” in Richard Fikentscher (Hg.) Beiträge zur Fertilität und Sterilität. (Beilageheft zur Zeitschrift für Geburtshilfe 152) (Stuttgart: Enke, 1959), 42; R. Kaden, “Zur Problematik der hormonalen Therapie bei Subfertilität,” in Richard Fikentscher (Hg.). Beiträge zur Fertilität und Sterilität. (Beilageheft zur Zeitschrift für Geburtshilfe 168) (Stuttgart: Enke, 1968), 25–30, here: 25. On internal factors, see Doepfmer, “Prophylaktische Maßnahmen zur Verhinderung der männlichen Infertilität,” 15–17. 87 Petersen, Unmasking the Masculine, 41. 88  Frevert, “Umbruch der Geschlechterverhältnisse? Die 60er Jahre als ­geschlechterpolitischer Experimentierraum.” The 1960s have been understood as an interim phase, producing but similarly limiting sociocultural changes. See Herzog, “Sexual Morality in 1960s West Germany,” 122–4. 89  Orland, “Die menschliche Fortpflanzung im Zeitalter ihrer technischen Reproduzierbarkeit”; Schreiber, Natürlich künstliche Befruchtung.

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7 “Cherishing Hopes of the Impossible”: Mothers, Fathers, and Disability at Birth in Mid-Twentieth-Century New Zealand Barbara Brookes David Cameron, now the prime minister of Britain, said in 2004 that the realization that his eldest son, Ivan, was severely disabled hit him “almost like mourning – the loss of something – mourning the gap between your expectation and what has happened.”1 The wealthy and highly educated Camerons were open about their son’s severe disability, Ohtahara syndrome (a combination of cerebral palsy and epilepsy). Sixyear-old Ivan’s death in 2009 was marked in the English Parliament and occasioned an outpouring of sympathy for the Cameron family. David Cameron’s willingness to acknowledge his son’s condition signalled a new era in the acknowledgement of childhood disability, a move away from the shame that had existed in both the United Kingdom and many of its former dominions in the twentieth century. The meanings associated with “disability” and, indeed, the word itself have been contested internationally by activists who reject “the medicalization of disability as individual pathology.”2 In New Zealand, historian Margaret Tennant has been at the forefront of considering how the meanings of disability have changed over time.3 A focus on the social model of disability, growing out of the interdisciplinary field of disability studies, has highlighted the way society discriminates against the differently abled and how disability is not about individuals, or necessarily about health, but about the wider society. Historians, in turn, have begun to respond to Catherine Kudlick’s 2003 challenge that an examination of disability, just as crucially as an examination of gender, race, and

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class, leads to central questions about our past, such as “what does it mean to be human?”4 An historical approach allows us to see how ideas about health were once closely tied to narrow conceptions of “normal development” and how people who deviated from the norm, such as children with Down syndrome, were regarded as “unhealthy” and best removed from society. Disability from birth is not an individual but a family affair. Hence it raises issues that complicate binaries about gender and health. The birth of a child with congenital abnormalities shapes the intimate world of family life, and at the basis of the family is a historically specific, gendered contract between the woman and man. The traditional words of the marriage service that promise partnership “in sickness and in health” marked the couple’s commitment to each other through the impact of illness. But what of the care of children? For most of the twentieth century, when a child was disabled the burden of care fell upon mothers. As one father of a severely impaired son put it, the child’s “management” was “a woman’s role.”5 Fathers, as breadwinners, were expected to provide the necessities of life for their families, while mothers were entrusted with attending to the health of the rising generation.6 That these gendered responsibilities with regard to health have a long history is clear in Patricia Reeve’s analysis of working people in nineteenth-century New England and Marjorie Levine-Clark’s analysis of entitlement to relief in early twentieth-century England (see chapters 1 and 2 in this volume). The differential responsibilities of parents with respect to family health have been shaped by the expectation that women’s primary role is that of mother. Rebecca Godderis’ contribution to this volume (see chapter 12) suggests that increased American attention to postpartum depression among women in the 1980s reflected a particular historical moment of rising concern about the disintegration of the family. The role of fatherhood is at the heart of Antje Kampf’s discussion of male infertility in Germany (see chapter 6). Both of these themes – of the depressed mother, and fathers’ contribution to their children’s heredity – are relevant to my analysis of parental responses to infant developmental delays in the mid-twentieth century. A child born with brain ­impairment could not be considered in isolation: parents were crucial to their future and mothers and fathers might disagree about where that future lay. At a time when an official committee could refer to a child with severe mental defect as “a being with human shape,” parents recognized that their mentally impaired children were, in effect,

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disenfranchised as citizens because of biology.7 The right to education was one among a number of common expectations likely to be denied. Parents in the mid-twentieth century looked to the medical profession for answers to developmental delays. From their perspective, their child had a health problem requiring medical expertise for diagnosis and assistance. They were complicit with the medicalization of disability while at the same time aware of the medical profession’s limitations. Indeed they were likely to blame themselves – their own internal pathology – in the first instance for their child’s difficulties, rather than the wider society. Many conditions were exceedingly difficult to diagnose, such as internal brain injuries that made no obvious markings on the body. Although the physical characteristics of infants with Down syndrome had been described in 1866, the reason these babies were different was unknown until 1959.8 Parents concerned about their child’s development usually visited the doctor’s office in search of explanations. My focus here is on New Zealand from the 1940s to the 1970s and my interest is in how a particular form of family health crisis had gendered repercussions. Mothers and fathers reacted differently to the birth of a mentally impaired child, putting the marital relationship under great strain. Whether or not to keep a child at home might be one of the points of contention between couples, with fathers more likely to initiate institutionalization.9 In these decades, most medical professionals were men who identified with fathers and sometimes discounted the views of mothers. The needs of mentally impaired children had implications for public culture, and in the 1950s their parents began demanding greater state resources for them.10 Parents contested the way their children were denied opportunities because of an accident of birth. I suggest that it was the actions of these united parents that helped to overturn the shame of disability and brought about significant social change. Activist mothers and fathers of disabled children believed that their children had the same rights as “normal” “healthy” children and, in particular, the right to education.

The New Zealand Context New Zealand was a British colony until it achieved dominion status on par with Australia and Canada in 1907. The country originally had a small population of Pakeha settlers (white New Zealanders), who from the 1840s onwards rapidly overtook the indigenous Maori people and

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dispossessed them of their lands. Most of the settlers were emigrants from Britain. By the mid-twentieth century, New Zealand had a population of around two million, 120,000 of whom were Maori. The relatively small size of the population enabled a close engagement between citizens and the state. The advent of a Labour government in 1935 ushered in a commitment to a welfare state, and an ideal of the country as a good place to bring up children. Labour drew on a history of in­ novation in child health and welfare instituted by the national Society for the Promotion of the Health of Women and Children. The society (known as the Plunket Society) was founded in 1907 by the charismatic Dr Frederic Truby King, who developed an international reputation in infant welfare.11 New Zealand prided itself on being a country where the possibility existed “for everybody to lead a happy life, free from fear of poverty.”12 The introduction of the 1938 Social Security Act meant that visits to the doctor were heavily subsidized and maternity care was free from May 1939.13 Free prenatal and postnatal care by doctors led to the expectation that healthy children would result. A child born with disabilities therefore confounded such hopes. A 1947 Department of Health booklet entitled Suggestions to Expectant Mothers starkly warned, “A baby fed for the first nine months of its life on impure blood (due to any condition of ill health in the mother) comes into the world handicapped.” Mothers were to have plenty of fresh air, eat well, take exercise, and get plenty of rest and sleep.14 After 1907, if a child was born with a severe “handicap” (in the language and perspective of the time), such as spina bifida, Down syndrome, hydrocephalus, or cerebral palsy, he or she might be sent to the Sisters of Compassion, a Catholic charity, to be looked after in a home at Island Bay, Wellington.15 Other such children who survived might be sent to one of the country’s public mental institutions. By 1920, the minister of public health and education, C.J. Parr, was arguing for the separation of children from adults in mental hospitals and made arrangements for children to be concentrated in one institution at Nelson.16 By 1943, this facility, which accommodated a hundred children and accepted babies, was “always full” and had a waiting list. Many of the children had Down syndrome; some had microcephalus, and other types of congenital conditions. “No matter how young they are,” an observer commented, “as soon as they enter the home, they are given constant training in cleanly habits and taught to walk and feed themselves.”17

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Every preschool child was supposed to be medically examined once a year by the Division of Child Hygiene. If abnormalities were detected in these inspections, or in examinations by school medical officers, children might be channelled into “special school, special classes, or other institutions as may be necessary.”18 From 1929, the state aimed to segregate older mentally disabled children from the mentally ill and provided care for them at Templeton Hospital and Farm, in the South Island.19 Children who were regarded as uneducable were to be the province of the Mental Hospitals Department. Psychopedic institutions such as Templeton and Levin Farm (which opened in 1945 in the North Island) had a twofold purpose.20 They relieved parents of the burden of care and the wider society of anxieties about reproduction of the “unfit.” Just who was “unfit” was not always easy to determine. When an abnormality was obvious at birth, how did parents respond to the news? How did mothers and fathers face the prospect of a family future different from the one they had imagined? How was the joint project of parenting reshaped by the advent of a child with mild to ­severe developmental difficulties? A pattern of a lack of diagnosis at birth, self-blame, unhelpful doctors, unsure prognosis, and institutional care as the answer shaped the experience of many parents in the mid-twentieth century. In the context of post-war optimism about building a better world, and with the baby boom leading to crowded maternity wards, the project of parenting could hold hidden hazards, such as a child’s mental impairment.

Disability and Historical Silence Oral history provides an avenue into the issue of disability and historical silence. As I was searching to provide a context for one mother’s experience, I found a unique set of sources: public health research reports completed by fifth-year medical students at the University of Otago. A group of medical students interested in the impact of disabled children on families had privileged access to mothers and fathers who shared their stories of difficulty. The students wrote up their findings in reports that contain rich records, including photographs of children. The latter are a reminder of an absence of congenital disability in the visual record of the nation that mirrors the silence that once existed on the issue. Here is one mother’s story, bridging England and New Zealand.21 Helen was a medical student in London in the late 1940s when her son was born prematurely at eight months’ gestation. She had hemorrhaged

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during the pregnancy. She recalled, “It was a bit of a surprise having a very very handicapped child. He lived until he was six, but it was pretty much touch and go the whole time. He never ever managed to walk or feed himself, or talk or anything like that, he was very very badly handicapped.” Helen’s general practitioner was no help in identifying what was wrong with her son and when she expressed her concern about his lack of normal development, he told her that “medical students were often rather stupid this way and often thought there was something wrong and there wasn’t.” At about six months, concerned that the infant wasn’t focusing at all and that he might be blind, she asked her parents for help and they arranged for her to take the child to an ophthalmologist. Unlike her general practitioner, this specialist confirmed Helen’s diagnosis, saying “medically you are quite right, he is 75% blind, there is little sight and the optic nerve hasn’t developed.” Helen determined to learn Braille and organize her life to assist her son, but further diagnoses were to follow. Helen found it very difficult to talk about their son’s condition with her returned serviceman husband, Patrick. When she did, he said that “he thought this child had been born damaged because of some of the things that he had done in the war.” Helen did not feel the same kind of guilt, but she said, “But I did feel perhaps I got up when I shouldn’t have got up, with the miscarriages, or I should have done something a bit better … in order to have had a child that hadn’t been damaged.” Her mother-in-law encouraged her to go to “healing services in churches in hope that the child would suddenly become better through God intervening.” She did so reluctantly, to please her mother-in-law, but did not hold out any hope. The couple considered whether they should “ever risk having other children.” Helen continued, “There were all these dreadful doubts which are hard to live with really. I have to admit at our worst times I considered organising a sort of mass [family] suicide … Then I … thought no, it’s too bad for my own family if I do this, but I did … think about it.” When her son was eighteen months old, Helen took him to a Harley Street pediatrician without her husband’s knowledge. The expert pediatrician told her that her son had microcephaly and that nothing would change. He said to her, “You’ve got two choices and it depends really on your income and your attitude to life. He said you either give up your entire existence to looking after him the way you are now and that would be for keeps, it won’t change. Or, he said, you do the opposite

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thing, you contact the London health authorities … It would all take time but he would be admitted to a paediatric hospital, psychopaedic hospital, they would definitely take him but probably not for another two years … but he said … I recommend the second because I don’t think it’s a useful way of spending your life looking after a child who is never going to really improve.” And so Helen put her son’s name down for institutional care. He was eventually accepted, and the couple felt terrible taking him to the hospital in 1953. They visited him weekly and cried “in the bus all the way home.” Someone suggested they consider emigrating to New Zealand, an idea that took root. They left the country, and Helen’s mother-in-law visited their son every week until he died, aged six, from pneumonia. That decision to leave their child shadowed the parents in their new life. The themes from this case study – the special responsibility of the mother and the importance of medical advice in the solution she sought – can be found in the lives of many parents of disabled children in the mid-twentieth century. But the knowledge of doctors, as this oral history suggests, was limited. In 1950, an international committee convened by the World Health Organization (W H O ) noted the limited state of psychological medicine and the lack of “comprehensive public mental health” services.22 Few doctors were trained in child psychiatry, however, and the call for the early diagnosis and treatment of what the W H O termed “mental subnormality” was thus difficult to answer. The committee declared that “the most important single long-term principle” for future W H O work with regard to mental health was to encourage “the incorporation into public-health work … [of] the responsibility for promoting the mental as well as the physical health of the community.”23 Perhaps in light of this directive, medical students studying public health in the fifth year of their course at the University of Otago, in Dunedin, New Zealand, were encouraged to explore the impact of what had become known as “intellectually handicapped” children in families.24 The results of their forays into the community were recorded in research reports that were archived by the medical school.25 A visit from a medical student to discuss their circumstances may have opened up an unusual opportunity for families, and mothers in particular, since they were the ones most likely to be interviewed because they were at home and provided the primary care.26 Mothers usually lacked a narrative to make sense of their experience – or an audience willing to listen – which meant it remained outside everyday cultural understanding.

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Two mothers reported suspecting that their babies had delayed development but found that their general practitioners dismissed their ­expert knowledge. In both cases the physicians sent them home with a “Don’t worry, my dear” and “We doctors can pick these children at a glance; your baby is perfectly normal.” Yet the professionals were wrong.27 There was little medical training in identifying such conditions and the New Zealand Medical Journal contained only one case report on congenital abnormality from 1935 to 1955. That report noted hemorrhaging during pregnancy, strangulation by the umbilical cord at birth requiring resuscitation of the newborn, and a history of congenital abnormalities involving fused fingers in the mother’s family.28 Both heredity and events during pregnancy and birth were clearly signalled as important in this case. By the mid-twentieth century, professionals placed less emphasis on heredity as a cause of intellectual handicap, suggesting that the birth of a “handicapped child to intellectually average parents” was a “piece of bad luck.” Nevertheless, they counselled that “marriage is not one of the prospects to which these children can look forward” since they were unlikely to be able to rear a family successfully “even if it were desirable.”29 The lack of study relating to children was one of the factors that prompted the founding of the New Zealand Paediatric Society, which held its first annual general meeting in May 1947.30 International experts were all too aware that the wider community often held the misconception that “mental subnormality occurs only among the children of the sinful, depraved, or shiftless.”31

Reacting to the Birth of a Disabled Child Women as mothers have been the focus of a number of historical works but questions about gender, children, and health have received far less attention.32 Leslie Reagan’s recent study Dangerous Pregnancies: Mothers, Disabilities, and Abortion in Modern America is path-breaking in this regard. Reagan examines the “specter of tragedy” wrought by the new knowledge in the 1960s that rubella caused serious birth defects. She further develops Rayna Rapp’s insight that women are today’s “moral pioneers,” negotiating the decision making involved with the choice of abortion in the face of new knowledge about abnormalities derived from tests such as amniocentesis.33 Before such testing was possible, it was the moment of birth that might reveal something of the prospect of a child’s future. But it was not

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always easy to tell, and the hope of an untroubled future could fade as developmental delays began to occur. At a time when fathers were routinely excluded from the birthing room, mothers anxiously enquired of their health professionals, “Is the baby all right?” They might be the first to be told that it was not, sometimes in an “abrupt,” “blunt,” or “cruel” manner.34 Sometimes doctors preferred to break the news to the husband man to man and to leave him to inform his wife.35 Doctors might also be falsely reassuring and leave it to the Plunket (child welfare) nurse responsible for postnatal visits to break the news.36 Such difficulties, because unexpected and tragic, often became unspeakable and, as a consequence, families became socially isolated. One mother recalled, “I had thirty-four baskets of flowers … My room looked like somebody had died … They weren’t welcome to your new baby kind of flowers, they were pots of chrysanthemums, the kind of flowers that you send to people when they lose someone, when someone dies … I didn’t have one baby card, I didn’t have one baby present and when a friend of mine came in with a pair of booties and bib I burst into tears. I said, ‘You are the first person that’s given me a baby present … My baby is still alive and you are the first person that has acknowledged that.’”37 The reactions of others quickly converted the pride of new parenthood into an often unspoken shame. Mothers were the ones more likely to interact with the health-care system (and generally with male doctors) and the local community. They were on the receiving end of sometimes remarkably cruel attitudes toward the disabled. One mother was “abruptly” informed that her newborn “had ‘no brain’ and would ‘never be any use.’”38 Eileen Coulthard’s daughter, Trish, sustained brain damage at birth in 1941. In 1953 she took her daughter to a doctor for an assessment. The doctor’s diagnosis consisted of the judgment, “I’m afraid your daughter is retarded.” When Eileen replied that her daughter was “intelligent, she can do lots of things” the doctor’s response was, “So can animals.”39 Mothers had to cope as best they could with unhelpful responses from professionals and the wider community.

C h a n g i n g A t t i t u d e s t o wa r d I n s t i t u t i o n a l i z at i o n For doctors in both Britain and New Zealand, institutionalization often seemed to be the answer to a range of congenital disabilities. The number of children with Down syndrome in the Nelson facility suggested the stigma attached to the condition and parental hopes that their children

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would receive some training. Institutional care also meant that children would be cared for beyond the lifetime of their parents. The development of antibiotics during the Second World War increased the survival rates of children with compromised health. Hence new ways of thinking about disability had to be found in the post-war world. Problems in raising disabled children rubbed up against the emphasis on a happy family life advanced in the late 1940s and 1950s. A happy family was a healthy family but a new importance ascribed to the role of mothers suggested that all children, whatever their health status, would benefit from their mothers’ love. The child-centred family, promoted by  a developing interest in psychological theory, stressed the role of mothers in the home. John Bowlby’s 1951 book Maternal Care and Mental Health emphasized the importance of attachment in infant development and heightened concern about institutional care.40 In 1951 the New Zealand Woman’s Weekly introduced a new advice column entitled The Psychologist’s Consulting Room, which encapsulated a shifting ethos toward considerations of mental health within the family. Radio also offered lessons on mental health. “It is a commonplace in psychology nowadays,” a psychiatrist stated in a 1957 radio lecture on the family, “that adult personality and beliefs, customs and manners which characterise the social order are largely the outcome of childhood experience.”41 New Zealand’s pioneer of analytical psychotherapy, Maurice Bevan-Brown, M D , emphasized in his book The Sources of Love and Fear how a child’s early relations with its mother set “the pattern for all subsequent relationships.”42 When a child was severely disabled, the extent of care required might be beyond the emotional and financial capacity of most ordinary households. But those with less severe problems might also be institutionalized. A key factor in the decision was “the ability of the mother to cope” if a child stayed at home.43 The impossible task of being the perfect mother became even more fraught when a woman was faced with a child who had a variety of unforeseen needs. The normal trait whereby a woman tended “lavish affection on the helpless” became subject to criticism when her attention was directed to a handicapped child, making her “blind” to the “important needs and rights of her other children.”44 A view that so-called “normal” children in the family would suffer if a disabled child remained at home was widespread. The demands of a disabled child were regarded as taking a mother’s attention away from her other children, to their detriment, as if families had a closed and limited circle of emotional energy.

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T h e I m pac t o n F a m i ly L i f e The way in which parents learned of their newborn’s disability could be crucial to their ongoing commitment to their child. The W H O 1953 Joint Expert Committee on the Mentally Subnormal Child noted, “The discovery that a child is subnormal will inevitably come as a profound shock to parents. In many cases they will feel a groundless personal guilt or will, half-consciously, blame their marriage partner for the child’s condition.”45 The committee’s recommendation was that parents should be given full and frank information, but if doctors knew little they were unable to provide such help. In a careful study, one female medical student interviewed ten families who had kept their child with Down syndrome at home and nine who had chosen institutional care. One further family, who had chosen institutionalization for their severely impaired daughter aged eleven, refused to be interviewed, wishing to “forget all about their child.”46 Not one of the nine of the families interviewed who had chosen institutional care believed they had been informed of their child’s disability in a satisfactory manner. Six thought “they had been told too late” (one child was two when the family received the news) and the same number thought “they had been told very badly.” Doctors had either been evasive or abrupt. One doctor had broken the news via the telephone. Six of the ten families who had chosen to keep their child at home were much more positive about the way in which they had learned about their child’s disability.47 Three out of nine families who had admitted their child to the local institution said they acted “partly because of a doctor’s advice.”48 One mother, Mrs R, followed her doctor’s recommendation that her eldest daughter, Wendy, be institutionalized because “she should be among her own kind.” Here the doctor reinterpreted kinship, seeing it not as a familial bond but as a bond of difference. The four subsequent children in the family never saw their sister and rarely heard their parents discussing her: in effect familial kinship was denied.49 Relations between couples could be severely strained: the nuclear family could implode under the weight of a child’s disability. At a time when companionate marriage was promoted as an ideal, a husband might resent the amount of time his wife devoted to a child who deprived him of her company. One father refused to countenance his wife’s wish that their child with Down syndrome accompany them on holiday.50 Another father of a severely handicapped child “refused to

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recognize the child for three weeks.” He gradually came to accept this child and a second with a disability but “blamed the mother” for the children’s disabilities “since her family have a history of mental deficiency.”51 It seemed that someone was to blame and parents took on guilt in all sorts of ways. “I wonder whether it was because I went out too much before he was born?” said one mother. “I suppose I was too fond of dancing when I was young,” said another. “I wonder if I’ve been too selfish?” was, apparently, a frequent question.52 Sometimes men coped by leaving. One husband did not want a handicapped child in the house so left when the child was an infant.53 Another avoided being seen in public with his disabled son, leaving him in the car when going shopping.54 One father ignored his disabled daughter, born in 1959 with cerebral palsy. For him it appeared to be a “matter of pride.” In this household the mother managed to preserve “family harmony.” Determined not to institutionalize her daughter and assiduous in seeking aid, she remained optimistic in the face of an unsupportive medical profession that “scoffed” at her enthusiastic approach.55 One couple, whose eldest daughter, Lorraine, was institutionalized in the 1940s, did not discuss her existence although the mother, Mrs D, kept visiting her. Harmony in the family was maintained through denial. The veil of silence across the existence of Lorraine was such that the mother would not be interviewed about her experience in her own home, only in a parked car. At the time of her interview in 1966, her two sons, aged 19 and 17, were unaware that they had an elder sister. Mrs D’s doctor advised her “to stop visiting her daughter because it upset her too much.” The strain of her ruptured relationship with her child was such that Mrs D said “she would have killed her next child had it been deficient.”56 Mothers were caught between the loving protection they felt for their children and the expectations of family members and a social climate that suggested they “get on with their lives,” forget their disabled child, and commit them to an institution. Doctors might encourage institutionalization. One, for example, “encouraged placement but left it to the father to force the decision.”57 The mother in this case was said to realize that “placement [was] the correct and rational decision” but had “not adjusted” to the situation, lavishing affection on her other children. The medical student sitting in judgment on her noted, “Placement has released her from introversion, but she is now introspective and regretful.”58 Of another devoted mother, who had created a happy home for her son, a male student casually wrote, “She could probably part with him without too much grief.”59

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Early placement, in the medical view, saved parents – and mothers in particular – from distress. Mothers in particular suffered from the medical profession’s unhelpfulness. But perhaps male doctors saw no way to be helpful. In an address to the Royal Australasian College of Physicians in 1955, a leading expert on cerebral palsy and allied conditions noted, “The study, diagnosis, assessment and management of this group of conditions in the Dominion are in a very unsatisfactory state, and appear to be drifting away from the medical profession into the hands of ancillary workers and even the laity. The medical profession of the Dominion is ill-­ prepared to assume these responsibilities and, in the absence of men fully trained in neurological medicine, cannot get easily the help it needs to play its part.”60 With little exposure to the specialized field of developmental disorders, and at a remove from educational developments, the focus of general practitioners remained on the family as a whole. In the mid-twentieth century, families relied on the work of mothers to keep the home both in terms of domestic duties and emotional stability. Here we might also speculate that male doctors identified with the difficulties facing fathers. This kind of identification is evident in one father’s recollection of a consultant who said of his child with cerebral palsy, “Oh, I’m glad it’s not my son.”61 Men’s self-esteem seemed particularly vulnerable to being eroded by their child’s visible handicap.62 None of the studies by the medical students clearly reveal a difference in immediate parental reactions determined by the sex of the disabled child. An American overview of fathers’ attitudes compiled in 1983 by Michael Lamb, however, suggested that because fathers held out high hopes for their sons, they were “especially disappointed when they have retarded sons.” Lamb found that fathers had a greater concern about their children’s long-term prospects and that the birth of a disabled child made them feel a failure. Perhaps, Lamb posited, because breadwinning fathers were more distant from their children they had “fewer concrete reminders of their value and competence.”63 Struggles between marital partners are all too apparent in the interviews. One mother, clearly deeply attached to her severely disabled ­seven-year-old son (born in 1965), wept when discussing her decision to institutionalize her child. She had to choose between losing her son and losing her husband, who had threatened to leave the family if the boy was not sent to an institution.64 Two mothers of daughters aged nine (born in 1963) and six (born in 1966), respectively, revealed that their

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daughters were in care because “severe marital problems” would have arisen otherwise. One father made repeated efforts to have a child put in care but the mother did not share her husband’s enthusiasm for this solution.65 According to one medical student, the extent of a father’s attachment to a child “seemed to have a great bearing on the decision” on whether to keep the child at home.66 Some of the young medical students’ studies of the families of mentally disabled children are redolent with distrust of the motives of mothers. They saw the women as either indulging in “foolish overprotection” of their children or making “impossible demands” of them. A mother of disabled twins was judged by a medical student to exercise “intense overpossessiveness.” The student wrote, “She clings intensely to the twins with a determined devotion, more suggestive of resentment than love.” Yet a mother whose daughter was in an institution was described as “emotionally shallow and self-centred,” someone whose “maternal feelings wane” when faced with “heavy responsibility.”67 Mothers were more likely to come in for criticism than fathers who retreated to the world of work daily and had respite from the burdens of care in the home. Mothers were said to “neglect their personal appearance, become homebound, give up their social contacts and holidays” and, as a result, age “prematurely.”68 Mothers of only children who were handicapped were counselled to have another child to prevent them from being “too intensely wrapped up” in their disabled child’s needs.69 Mothers occasionally refused to accept their child, but this was much more likely to be the response of fathers. A large-scale survey carried out in the early 1970s in New Zealand indicated that “mothers had sole responsibility for considerable numbers of the intellectually handicapped, and for an increasing proportion of those in the older age groups.” Examples ranged from a divorced 22-year-old mother working and caring for her son with Down syndrome with the help of her parents-in-law, to a 97-year-old Maori woman living in a rural township caring for her 20-year-old great-grandson “whom she had reared from childhood.”70 Maori families, where support of the wider kin group was expected – and available – were much less likely to choose institutionalization for their children. The wider kin network meant that mothers were released from the primary expectation of care. “Significantly more” disabled Maori children “were the responsibility of other relatives, most notably grandparents.”71 Nearly one-fifth of intellectually handicapped Maori children were in the care of people other than their own parents compared with slightly over one-tenth of such Pakeha children.72

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Lobbying for a Better Life Mothers of children judged too handicapped for special classes had taken initiatives as early as the 1930s to get access to education for them. In 1935 they led a deputation to the government saying that their children “had simply been turned out on the scrap heap and left there.”73 Little changed, however, until the founding of the Intellectually Handicapped Children’s Parents’ Association (I H C P A ) in 1949. The title of the organization was significant: only parents or guardians were entitled to vote and hold office. They, rather than the so-called experts who had proved so disappointing to many, were to determine their future.74 Parents sometimes worked together to find avenues of support. Margaret and Harold Anyon, whose youngest son Keith was born with Down syndrome in 1936, were told that he would never go to school. The doctor told Margaret that she “deserved something better.” A welleducated and politically savvy woman, living in the nation’s capital city, Margaret Anyon was tireless in her efforts to find treatment for her son.75 She began a quest for educational opportunities for him that soon widened to involve other parents seeking help for their children. In 1949, the Anyons placed an advertisement in a Wellington newspaper inviting “parents and guardians of backward children” to a meeting. The children of those who attended were variously placed. Some were cared for at home, others were in institutions. Three were in special classes; one child was in Levin Farm. Eight children had Down syndrome, two children had cerebral palsy, one child had brain damage, and one had an unspecified condition.76 No longer were these urban parents struggling to make sense of their issues alone: they shared a “social fund of knowledge” that empowered them to take their private stories into the public domain.77 The I H C P A gave them a focus to bring about change and to contest existing definitions of “normal” development. In seeking a wider range of solutions than the automatic institutionalization recommended by so many doctors, the I H C P A lobbied the government for an inquiry. Its members were particularly concerned with the anomaly that denied their children what was freely provided for “normal” children: educational, health, and social amenities. They also wanted a wider range of residential options and more research into disabilities. In 1951 the government set up a consultative committee of inquiry to consider the facilities available for intellectually handicapped children and appointed as chair Dr R.S. Aitken, vice-chancellor of the

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University of Otago. The I H C P A was dismayed that the committee had no parent representative, no woman member, and no member with social work expertise. Once again male professionals with little hands-on experience appeared to be setting the terms on an issue that primarily affected women in the home. Eventually the government responded to the I H C P A ’s complaints by appointing Miss Jean Robertson, a senior lecturer in social science, to the committee.78 The committee’s report, known as the Aitken Report, stated unequivocally that residential care was the best option for those it termed “imbecile” children. The language of the report could only serve to incense parents who had looked to the government for assistance.79 The report chided parents for holding unrealistic expectations. The authors were “glad” that the majority of parents they interviewed “realized and accepted the limitations imposed by the degree of mental defect, and did not cherish hopes of the impossible.”80 “Until recently,” the Aitken Report asserted, “the parents of an imbecile child have more often than not been ashamed of their misfortune and prone to conceal their child from public attention; they have suffered from a confused feeling of guilt and sometimes from a fear of having more children, lest they too should prove to be defectives. The public in general has tended to regard the presence of an imbecile child as a stigma on a family.” There was good evidence that the children were shunned in local communities. That such attitudes were in  the process of changing was, the report optimistically continued, due to “the propaganda of the Intellectually Handicapped Children’s Parents’ Association.”81 I H C P A members were bitterly disappointed that the government investigation for which they had lobbied had resulted in an affirmation of institutionalization. They responded with a publicity campaign about the needs of “handicapped children,” publicizing their preferred term over the language of “idiots” and “imbeciles” still used in the Aitken Report. Historian Margaret Tennant quotes newspaper headings from the time designed to capture attention to the cause, such as “Shocked Parents Allege I.H. Children Driven into Mental Homes.”82 Association members would not rest until the government recognized the need for enhanced educational and respite care facilities for their children. Change at the official level – if not in the community – was rapid. In 1958, a subcommittee of the New Zealand branch of the British Medical Association produced a report debunking the Aitken Report’s recommendations, finding no evidence that children did better in institutions

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than in their own homes. This report was far more optimistic about the educational potential of mentally disabled children and far less confident about the precision of diagnosis in young children. That report enabled parents to “cherish hope” of what was once thought to be ­impossible: a future in which their children enjoyed integration into the community. Mothers were central in the I H C P A movement, although the key officials were usually hard-working men, reflecting the gendered assumptions of the wider culture.83 But women worked at the branch level, raising funds, seeking educational opportunities, and sharing information. They seized with relief upon Pearl Buck’s 1950 best-selling book The Child Who Never Grew (serialized in both the ubiquitous Readers’ Digest and the Ladies Home Journal), in which she urged parents of mentally disabled children “not to despair or turn away in shame. This child has a meaning for you and for all children.”84 Buck was an extremely prolific and popular novelist who had been awarded the Nobel Prize for Literature in 1938.85 In the late 1940s, she turned to autobiography, writing the story of the birth and early years of her “retarded” daughter, Carol, whom she had eventually decided would best be looked after in an institution. Buck’s book insisted that disabled children were not the result of heredity and she helped shift the view of such children from being potentially dangerous mental “defectives” to one in which they were regarded as innocent children locked in childish understanding.86 Buck’s book quickly became a key text assisting parents to understand their child’s mental impairment free of the earlier stigmatizing attitudes.87 In her book, many mothers found the words to express feelings that they had been unable to voice before.

Conclusion In mid-twentieth-century New Zealand, gendered expectations shaped the care of developmentally delayed infants. A child’s impairment had a direct and taxing emotional and physical impact on mothers in particular and on the health of the family overall. The best care for the health of the child required family decision making, and unity between husband and wife on those decisions increased the likelihood that the family would achieve good outcomes for both the parents and the child. A mother’s ill health or depression could lead directly to the institutionalization of a child.88 Yet mothers might also resist institutionalization for their children, against the wishes of their husbands, in the belief

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that they could provide a nurturing environment. In that case they had to manage not only the needs of the child but also the risks of a ruptured marital relationship. There is a suggestion in the limited evidence available that the father’s attitude, in the majority of cases, was crucial to whether or not a child was institutionalized. Loving fathers could assist in the care of their impaired child but the wider social context, which expected men to act as breadwinners, meant that they were usually unavailable for the quotidian tasks required in the home. For some men, institutionalization seemed to be the best way to preserve a “normal” family life: to protect other children and to give couples time together. The believed beneficial nature of institutions for mentally impaired infants, however, came under review as new studies emerged in the early 1950s about the psychological importance of infant attachment. Studies like those of John Bowlby, the key figure associated with the term “maternal deprivation,” led some doctors and parents to re­ evaluate their assumptions about institutional care. New psychological theories about the well-being of children underpinned moves to seek a wider range of support services for the mentally impaired and their families. Parents who cherished hope, in the face of some medical disapproval, worked hard to create support for their children’s needs. Mothers and fathers who remained together and committed to providing opportunities for their children demanded that their expertise be recognized. Those who organized to fight for the rights of the disabled, and held out hope for the future, worked to overturn the shame that mothers and families had been made to feel. They refused to accept their status as lesser parents and sought assistance for their children in all sorts of ways. Organizations advocating for the disabled worked to shame the wider culture for its inability to accept difference, providing a framework for the current social, rather than medical, model of disability. Through their activism they provided a public narrative about disability that had the potential both to assist individual parents, but mothers in particular, and to bring about wider social change.

Acknowledgments I thank Diana Brown, Angela Findlay, and Elspeth Knewstubb, all of whom provided invaluable research assistance in the preparation of this chapter.

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notes   1  Sue Lawley interview with David Cameron, Desert Island Discs, 2006, http:// www.bbc.co.uk/radio4/features/desert-island-discs/castaway/8d5bcfbc. See also Alistair Jamieson, “David Cameron on son Ivan: ‘We’re going to get through this he’s lovely,’” The Telegraph (25 Feb 2009), http://www. telegraph.co.uk/news/4804307/David-Cameron-on-son-Ivan-Were-goingto-get-through-this.-Hes-lovely.html  2 Snyder and Mitchell, Cultural Locations of Disability, 9.  3 Tennant, “Disability in New Zealand: An Historical Survey.”  4 Kudlick, “Disability History,” 764. On parenting and intellectual disability see Brockley, “Rearing the Child Who Never Grew.”  5 A.M.G. “A Survey of Families with I.H. Children in Institutions and at Home,” Preventative medicine diss., University of Otago School of Medicine, 1962, 30.   6  Brookes, “The Risk to Life and Limb: Gender and Health,” 287.  7 Intellectually Handicapped Children, Report of the Consultative Committee set up by the Hon. Minister of Education, August 1951 (Wellington: Department of Education, 1953), 18. On the idea of “biological citizenship,” see Rose and Novas, “Biological Citizenship.”  8 Wright, Downs: The History of a Disability, 115.  9 A.M.G. “A Survey of Families with I.H. Children,” 41. 10  Rapp and Ginsburg, “Enabling Disability,” 537. 11  Brookes, “King, Frederic Truby.” 12  Burchfield and Burchfield, The Land and People of New Zealand, 12. 13  Mein Smith, Maternity in Dispute, 119–20. 14  New Zealand Department of Health, Suggestions to Expectant Mothers (Wellington: E.V. Paul, Government Printer, 1947), 4–7. 15  Tennant, “Mary Joseph Aubert.” 16  C.J. Parr, “Report on the Mental Hospitals of the Dominion,” Appendices to the Journals of the House of Representatives, 1921–1922, vol. 3 H-I, 2. 17  J.M.E.J., “Study on the Problem of Mental Deficiency and Backwardness in New Zealand Children and the Measures Adapted to Deal with It,” preventative medicine diss., School of Medicine, University of Otago, 1943, 55–7. 18  New Zealand Official Yearbook, 1947–49 (Wellington: R.E. Owen, Government Printer, 1950), 108–9. 19 Tennant, The Fabric of Welfare, 102. 20  Anne Hunt discusses the history of the Levin institution in The Lost Years: From Levin Farm Mental Deficiency Colony to Kimberley Centre. 21  Interview with H.A. Dunedin, 7 September 2006.

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22  World Health Organization, The Mentally Subnormal Child: Report of the Joint Expert Committee Convened by w h o with the Participation of United Nations, i l o , and u n e s c o , Technical Report Series, no. 75 (Geneva: World Health Organization, 1954), 4. Citing the World Health Organization Technical Report Series 1950, 9, 7. 23  World Health Organization, The Mentally Subnormal Child: Report of the Joint Expert Committee Convened by w h o with the Participation of United Nations, i l o , and u n e s c o , Technical Report Series, no. 75 (Geneva: World Health Organization, 1954), 4. 24  This term was promoted by the New Zealand Intellectually Handicapped Children’s Parents’ Association; see Millen, Breaking Barriers, 14. 25  These research exercises were part of the students’ coursework and contain a mine of information on all sorts of topics. The students were young and inexperienced and that has to be taken into account in reading the theses. I have not named the authors out of respect for the fact that they did not imagine their work would enter the public domain. Because most of the authors just used initials, it is difficult to determine the ratio of male to female authors. 26  In one of the studies, which involved twenty families, the father was present in six of the interviews. K. C., “A Comparison of Institutionalised and Home-reared Mongol Children,” (preventative medicine diss., University of Otago School of Medicine, 1972, 11. 27  S.L.M. “The Intellectually Handicapped Child,” preventative medicine diss., University of Otago School of Medicine, 1974, 4. 28  Hilda Northcroft, “Case of Congenital Abnormality,” New Zealand Medical Journal, 36, no. 191 (February 1937): 59 29  Ralph Winterbourn, Caring for Intellectually Handicapped Children (Wellington: New Zealand Council for Educational Research, 1958), 25. 30  Paediatric Society of New Zealand, “History of the Paediatric Society of New Zealand,” www.paediatrics.org.nz/files/History%20of%20Paediatric%20 Society.doc 31  World Health Organization, The Mentally Subnormal Child, 36. 32  On motherhood in New Zealand see Bryder, A Voice for Mothers; Mein Smith, Maternity in Dispute; Donley, Save the Midwife. 33 Reagan, Dangerous Pregnancies, 103; Rapp, Testing Women, 306–11. 34  A.M.G., “A Survey of Families with I.H. Children,” 44. 35 Winterbourn, Caring for Intellectually Handicapped Children, 39. 36  A.M.G., “A Survey of Families with I.H. Children,” 18–19. 37  Bennett, “‘An Emotional Roller-Coaster’: Stories from Mothers of Young Disabled Children,” 31.

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38  A.M.G., “A Survey of Families with I.H. Children,” 29–30. 39 Millen, Breaking Barriers, 19. 40  John Bowlby, Maternal Care and Mental Health (Geneva: World Health Organization, 1951). 41  Listener, 4 October 1957, 4. 42  M. Bevan Browne, The Sources of Love and Fear (Christchurch: Raven Press, 1960), 10. 43 Winterbourn, Caring for Intellectually Handicapped Children, 15. 44 Winterbourn, Caring for Intellectually Handicapped Children, 35. 45  World Health Organization, The Mentally Subnormal Child, 15. 46  K.C., “A Comparison,” 9. 47  Ibid., 21. 48  Ibid., 20. 49  S.B.C, “The Families, the Doctors, the Community and 14 Intellectually Handicapped Children,” preventative medicine diss., University of Otago School of Medicine, 1966, 4. 50  K.C., “A Comparison,” 30. 51  A.M.G., “A Survey of Families with I.H. Children,” 8. 52  Millicent Kennedy and H.D. Somerset, Bringing up Crippled Children: Suggestions for Parents, Teachers and Nurses (Wellington: New Zealand Council for Educational Research in association with New Zealand Crippled Children Society, 1951), 76–7. 53  M.R.M.B, “A Family Study of the Intellectually Handicapped,” preventative medicine diss., University of Otago School of Medicine, 1966, 7. 54  M.R.M.B. “A Family Study of the Intellectually Handicapped,” preventative medicine diss., 1966, 32. 55  A.M.G., “A Survey of Families with I.H. Children,” 17. 56  S.B.C., “The Families, the Doctors, the Community,” 13. 57  A.M.G., “A Survey of Families with I.H. Children,” 25. 58 Ibid. 59  Ibid., 12. 60  I.M. Allen, “Cerebral Palsy and Allied Conditions in Childhood,” New Zealand Medical Journal 54, 303 (October 1955): 582. 61  Donald Beasley Institute, Perilous Passage: New Zealand Fathers Talk about their Children with Disabilities, 4. 62  Lamb, “Fathers of Exceptional Children,” 135. 63 Ibid. 64  K.C., “A Comparison,” 8. 65  S.L.M., “The Intellectually Handicapped Child,” 12. 66  K.C., “A Comparison,” 50.

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67  A.M.G., “A Survey,” 27. 68 Winterbourn, Caring for Intellectually Handicapped Children, 34–5. 69  Ibid., 36. 70  A.A. Morrison, D.M. G. Beasley, and K.I. Williamson, The Intellectually Handicapped and their Families (Wellington: Research Foundation of the New Zealand Society for the Intellectually Handicapped, 1976), 100. 71  Ibid., 103. 72  Ibid., 103–4. 73  Rosemary Goodyear, “‘The Individual Child’: A study of the Development of Social Services in Education in Relation to the First Labour Government’s Educational Policy,” B A Hons diss., University of Otago, 1987, 85. 74 Millen, Breaking Barriers, 15. 75  Ibid., 8. 76  Ibid., 13. 77  Rapp and Ginsburg, “Enabling Disability,” 538. 78  Jean Robertson was on the staff of Victoria University College. The other members of the committee were Dr L.S. Davis, director of School Hygiene, Dr G.M. Tothill, deputy director, Division of Mental Hygiene, and F.C. Lopdell, chief inspector of primary schools. Millen, Breaking Barriers, 22–3. 79  Intellectually Handicapped Children, Report of the Consultative Committee set up by the Hon. Minister of Education, August 1951 (Wellington: Department of Education, 1953), 20 (hereafter referred to as the Aitken Report) 80  Aitken Report, 18. 81  Ibid., 34. 82 Tennant, The Fabric of Welfare, 156. 83  Earl, “Caring for their Children Forever,” 56. 84 Buck, The Child who Never Grew, back cover. My thanks to Dave Earl for sharing his work on the Australian situation with me and, in particular, pointing out the influence of Buck. 85  Conn, Pearl S. Buck: A Cultural Biography, 207–15. 86  Earl, “Caring for their Children Forever,” 7. 87  Ibid., 40–1. 88  K.C., “A Comparison,” 12.

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8 Breaking Down Barriers: Women in the Ontario H I V /A I D S Movement before the Advent of Antiretroviral Therapy N a t a l i e L . G r av e l l e Before and shortly after the term acquired immune deficiency syndrome (A I D S ) was coined in the summer of 1982, the mainstream press in Canada used terms such as gay cancer, gay-related immune deficiency, and gay plague to refer to the mysterious condition that was first noticed among young and previously healthy men presenting with Kaposi’s sarcoma or succumbing to a variety of opportunistic infections.1 When the condition was seen in a greater number of people who did not report same-sex sexual activity, Canadian journalists emulated epidemiologists and made use of the terms “risk groups” and “groups at higher risk” when discussing AIDS epidemiology. Even then, such language was problematic. Among other issues, the notion of risk groups offered too neat a compartmentalization of individuals and it con­founded identity and specific practices. Health and Welfare Canada’s July 1985 classification of adult Canadian patients with A I D S listed six  categories of people at greater risk for the syndrome: homosexual / bisexual men, intravenous drug ­users, hemophiliacs, recipients of blood transfusions / products (excluding hemophiliacs), and recent Haitian immigrants. The sexual partners of individuals who had one or more risk factors were also considered at risk and were identified in epidemiological reports under the category “others.”2 As was the case in the United States, the risk for (white, middle class) women in Canada was deemed marginal and Canadian scientific experts, public officials, and media commentators continued to link the  disease with gay men. As Cindy Patton and Paula Treichler have

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previously noted in their work examining gendered constructions of AIDS discourse, the early construction of AIDS as a gay men’s disease and subsequent references to male and nongendered risk groups in epidemiological discussions obscured women’s location in the emerging epidemic.3 Some women preoccupied with women’s health acknowledged women’s invisibility in A I D S reporting and challenged prevailing constructions of the emerging epidemic. For example, in a 1983 Healthsharing article entitled “A I D S Affects Us,” Lisa Freedman alerted the Canadian health periodical’s feminist readers to women’s potential susceptibility to A I D S through sexual contacts or donor insemination.4 She pointed to the fact that of the thirty-seven cases of A I D S reported to Canada’s Laboratory Centre for Disease Control by 9 September 1983, four (or 10.8 per cent) were women. She went on to note that in the United States, of the first 2,339 cases reported to the US Centers for Disease Control (C D C ), 151 (or 6.5 per cent) were women. Although feminist and lesbian and gay liberation magazines continued to publish articles on women, the human immunodeficiency virus (H I V ), and A I D S , their attempts to shed light on the matter were not widely recognized. It was not until the end of the decade that activists mobilized around H I V positive women’s health issues and by then, the prevalence of positive H I V diagnoses among women was rapidly increasing. Between 1985 and 1994, 3,014 women tested positive for H I V in Canada and the majority of them (1,183) lived in Ontario.5 The subject of women’s involvement in community-based responses to H I V and A I D S has received some scholarly attention in the United States.6 Issues pertaining to gender more particularly have been taken up in discussions of women’s participation in the A I D S Coalition to Unleash Power (A C T U P ).7 While several works have examined the ­history of community responses to the epidemic in Canada, women’s involvement in and contributions to the Canadian H I V /A I D S movement remain largely unexplored.8 This chapter enriches the history of H I V /A I D S activism by exposing women’s involvement in two provincial A I D S organizations and highlighting some of their contributions in  the period preceding the advent of more effective antiretroviral ­therapies in the mid-1990s. The construction of A I D S as a “gay men’s disease” created barriers to women receiving effective H I V /A I D S information, treatment, and support services. Women’s social and political involvement in the H I V /A I D S movement was a crucial step in redressing that situation. Using material from newsletters, newspaper

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and magazine articles, reports, community-based documents, and ­interviews, this chapter explores how women in Ontario involved in A I D S A C T I O N N O W ! (A A N !) and Voices of Positive Women (V O P W ) challenged the assumption that women’s experiences of living with H I V /A I D S were similar to those of men. These women acquired knowledge of treatment issues, and some developed advocacy skills, which they used to promote changes in the treatment of women living with H I V /A I D S .

AIDS Activism Emerges in Ontario In 1986, people living with H I V /A I D S (P H A s) had, for the first time since the beginning of the epidemic, reason to hope for a prolonged life. Results from a US clinical trial of the drug zidovudine (A Z T ) demonstrated that the drug slowed the progression of A I D S , and other promising drugs were undergoing testing. These, however, were not readily available in Canada and the lack of available treatment options meant that many P H A s were dying. In late January 1988, after months of struggling to understand medical and political issues related to the treatment of H I V /A I D S , concerned individuals in Toronto launched the political action group A A N ! Toronto was home to a vibrant and ­organized lesbian and gay community9 and gay political activists demanded that their health rights be recognized. “If this syndrome were affecting 1,500 Canadian Boy Scouts,” declared A A N ! co-founder Michael Lynch, “neither [the federal nor provincial ministers of health] would be reacting with such armchair leisure. They’re letting us die off because we’re gay.”10 When A A N ! launched a call for action shortly after the group was formed, approximately 400 people gathered at Jarvis Collegiate in Toronto, angry and frustrated with the slow pace at which the federal government made promising drugs available to P H A s.11 Most of those in attendance that evening were white gay men who had been affected by the epidemic; they had lost friends and lovers, knew or cared for those who were ill, and / or were H I V -positive themselves.12 Some were seasoned activists who had been involved in gay liberation and other social movements. Others were new to activism. Many were articulate, middle-class professionals and, together, they had the determination, skills, and ability to confront and work with governments, pharmaceutical companies, and H I V /A I D S researchers. The group was instrumental in bringing about policy changes in the  medical treatment of Canadian PHAs. Among other issues, it

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demanded that the federal government and pharmaceutical companies grant P H A s compassionate access to experimental drugs and that the Health Protection Branch of Health and Welfare Canada expedite its  review of new drug submissions. Under Canadian regulations, the Health Protection Branch (Drugs Directorate) was responsible for the review of all drugs marketed in Canada before they were made available to the public. Only when the Health Protection Branch had been satisfied that a drug was safe and effective for its indicated use did it authorize a manufacturer to market the drug in Canada. Drugs that had not yet received approval but were undergoing testing were available to patients who participated in clinical trials (many of which were double blind and placebo controlled, which meant that a determined number of participants were given a standard treatment or a placebo instead of the new drug, and neither they nor their physician knew what treatment they were getting) or patients whose physician had requested the drug through the Emergency Drug Release Program.13 Both channels presented challenges that A I D S activists addressed with some success. One of the first actions A A N ! undertook was to promote the prophylactic properties of aerosol pentamidine (A P ) against pneumocystis ­carinii pneumonia (P C P ), one of the most common opportunistic infections among P H A s. In a study conducted at San Francisco General Hospital, the aerosolized form of the drug had been shown to be effective in relieving P C P in thirteen of fifteen patients.14 However, since no drug companies had filed for permission to market the drug in its aerosolized form in Canada, it was not available there.15 Doctors treating P C P in Canadian hospitals used pentamidine intravenously, which proved more toxic and caused serious adverse reactions in some of the patients who took it. Knowing that A P could effectively treat P C P and that it showed promise as a prophylactic as well, A A N ! activists assembled and distributed information packages on A P and its use to P H A s and physicians. They also set up a telephone line for P H A s, offering callers life-saving information. Since it was possible for Canadians with a prescription for pentamidine to purchase the drug in the United States, their recorded message provided callers with information on where they could buy the drug in Buffalo, its cost, and the names of the Canadian physicians who were willing to supervise its use. Physicians of patients who did not react well to pentamidine should have been able to access the aerosolized form of the drug through the Emergency Drug Release Program. Established in 1967 by the federal government, the program was designed to enable Canadians with

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life-threatening conditions to get access to drugs that had not been tested or approved for use in the country.16 A patient’s treating physician who wished to obtain such drugs had to place a request with the federal program. Once the request was approved, the manufacturer, if it agreed to release the drugs, sent them to the requesting physician. Until late  1988, some physicians trying to avail themselves of experimental A I D S drugs through the Emergency Drug Release Program met resistance from staff in the Health Protection Branch (Bureau of Human Prescription Drugs) and found their requests rejected out of hand. For example, it appeared that dextran sulfate, a drug available in Japan to treat high cholesterol, slowed the replication of H I V in laboratory experiments, but federal officials denied the requests of Canadian physicians for its release. Some reportedly believed that if the drugs were released through the program, no one would volunteer to participate in Canadian clinical trials. P H A s with the means to do so were able to ­circumvent this obstacle by obtaining the drug through underground buyers’ clubs in the United States, others through mail order from the Bahamas and Jamaica.17 In January 1989, after months of taking their message to the streets and to the press, A I D S activists expanded their tactical repertoire and discussed ongoing problems of access to experimental drugs on Monitor, a local television program on the Canadian Broadcasting Corporation (C B C ). Shortly thereafter, the story ran on The Journal, a national current affairs television program on the C B C . The national broadcast helped A A N ! achieve one of its desired outcomes. In a telephone interview with staff of Toronto gay and lesbian newspaper Xtra! on 2 February, Dr Michele Brill-Edwards, acting assistant director of the Bureau of Human Prescription Drugs, said, “It was most disconcerting for us to see a report on the C B C Journal in which it appeared that a request for dextran sulphate was refused by one of our staff persons out of hand. We have since been trying to make it clear to doctors that the drug is available.”18 Elsewhere, she explained that officials handling requests for H I V /A I D S drugs were being too “bureaucratic” and that some physicians in the department did not understand the program, which was why they were refusing access.19 A A N ! activists confronted what many perceived as governmental indifference to the health needs of gay men and demanded that the health rights of P H A s be recognized and given the attention that circumstances dictated. While government administrative and policy changes followed, making a greater number of drugs to treat opportunistic infections available to P H A s, some manufacturers

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refused to release drugs through the Emergency Drug Release Program, compelling activists to continue, among other activities, to apply political pressure when manufacturers refused to release promising drugs through the federal program.

HIV/AIDS as a Women’s Issue Most activist actions carried out under the banner of A A N ! were of benefit to P H A s regardless of gender, race, or sexuality. The small group of women involved in treatment activism, however, played a key role in highlighting the particular problems affecting women with H I V /A I D S . These activist women joined A A N ! for various reasons. Lesbian and straight women with P H A s in their lives, intimately affected by the epidemic, supported the work of A A N ! Some lesbians joined the organization believing that A I D S -based coalition work could create a stronger and more unified lesbian and gay community.20 Professional women who worked in health-care settings and women’s health activists were moved to action by the absence of strong and effective H I V /A I D S policies and strategies. Finally, women living with H I V /A I D S whose very lives were on the line joined the ranks of activists, learning what they could about treatment issues and strengthening the movement with their determination to effect change. While lobbying for access to treatment and better care for P H A s, women involved in A I D S activism publicly challenged the general assumption that women did not get A I D S . With much of the discourse on H I V /A I D S focused on the notion of risk groups, many women and their physicians were unaware that they could be at risk for H I V infection. When women visited their doctors and reported that they were experiencing fatigue, fever, diarrhea, weight loss, and a range of gynecological irregularities such as chronic vaginitis and pelvic inflammation, physicians often overlooked the possibility of H I V infection. Like women in early stages of coronary artery disease, their symptoms were “considered to be atypical because diagnostic standards were mainly ­established from research on men.”21 Many women therefore did not suspect H I V infection, were misdiagnosed, or were diagnosed as H I V positive later than were men. All three of these scenarios posed a threat to women’s health by delaying early treatment intervention. In many cases, women learned of their infection after their sexual partners were diagnosed as H I V -positive, after they were hospitalized, or after their biological children became ill.22 When women did suspect H I V

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infection, their requests for an antibody test were not always taken seriously. One anonymous woman who participated in an A I D S treatment information needs assessment by the Community A I D S Treatment Information Exchange in 1991 indicated that a year before testing H I V -positive, she had asked her doctor for an antibody test and her doctor had said, “Don’t be ridiculous, what do you need that for?”23 Injection drug use or perceived sexual promiscuity rather than women’s concerns appear to have been the criteria some physicians applied in administering the test. To address the situation, activist women in A A N ! produced flyers, pamphlets, and articles for mass consumption to draw attention to the fact that sexually active women could and did get H I V /A I D S . They also encouraged women to get tested.24 They distributed promotional materials during International Women’s Day events and during rallies. Some women also introduced themselves as H I V positive during A A N ! demonstrations, and others participated in media interviews, offering powerful and corporeal evidence that A I D S was also a women’s issue. Activists sought to change the widely held view that A I D S only affected gay men and members of specific groups and in the process they became health educators. Activist women also exposed the research community’s gender bias by criticizing its portrayal of women generally and its lack of attention to women-specific matters. In the month leading up to the Fifth Inter­ national A I D S Conference in Montreal, A A N ! and other community A I D S organizations invited women to attend an activist teach-in at Toronto City Hall. A morning session for women only provided participants with an opportunity to strategize about how to have issues specific to women acknowledged during the conference; some of the other sessions covered new issues in H I V transmission as well as A I D S activism within diverse communities.25 During the conference, A A N ! activists joined forces with New York’s A C T U P chapter and Montreal’s Réaction Sida to focus attention on the treatment needs of P H A s as a whole, but they also participated in demonstrations to protest the institutional ­invisibility of lesbians and the scapegoating of sex workers in the epidemic. Together, they challenged assumptions that lesbians could not become infected (the implication being that lesbian sex was not real sex and that lesbians did not have sex with men) and that sex workers liked to do nothing better than transmit the virus (the implication being that sex workers were H I V -positive and that they did not use condoms while having sex with their clients).26 A A N ! member Mary Louise Adams observed that conference presentations discussing women depicted them

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“not as individuals whose health is threatened by H I V but as receptacles for the virus and transmitters of the virus to either children or men.”27 Little value was placed on women’s health independently of their relationship to others. Critics have noted that there were as many women living with A I D S in the late 1980s as there had been men living with A I D S earlier in the decade. Research on women’s health issues, however, failed to generate the same level of interest among researchers as they had demonstrated with men’s health issues several years earlier.28 Without women-specific research, women lacked the resources to make fully informed health-care decisions. It was known, for example, that certain medications, such as rifampin used in the treatment of tuberculosis, decreased the effectiveness of birth control pills.29 Women seeking answers to questions such as “How does A Z T interact with the birth control pill?” were better served by the informal conversations that took place during the conference and the evening meetings organized by the International Working Group on Women and A I D S .30 The need for more research on women and A I D S was cogently made during an A A N ! World A I D S Day demonstration on 1 December 1990. The theme of the day was “Women and A I D S ” and members of A A N ! staged a die-in to draw attention to the fact that women with A I D S died faster of H I V -related complications than men. It could be that women were diagnosed with A I D S at a later stage of infection than men,31 for reasons that will be discussed below, but as activists would point out, women lacked comparable access to treatments and services on account of their gender. After a rally at the 519 Church Street Community Centre in Toronto, between 100 and 150 protesters marched toward the offices of the Ontario Ministry of Health to participate in a demonstration they hoped would put pressure on Health Minister Elinor Caplan to improve services for people living with H I V /A I D S . As they marched, they chanted “Women die faster, A I D S is a disaster.”32 When they arrived at the intersection of Church and Wellesley streets, the heart of the city’s lesbian and gay community, and later Yonge and Wellesley streets, approximately thirty-five women died symbolically on the street while men drew the outlines of their bodies with chalk on the pavement. The outlines served as visible markers of H I V -positive women’s precarious health and the tragic impact of research agendas that devoted little attention to them.33 In addition to testing later than men, which denied women the benefits of early treatment intervention, one of the difficulties women faced was the definition that was applied for making an A I D S diagnosis.

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Between 1983 and 1987, Health and Welfare Canada adopted the C D C ’s A I D S surveillance case definition, which consisted of twenty indicators for those who tested positive for H I V : four types of cancers and sixteen opportunistic infections. Although the case definition reflected the most common epidemiology of A I D S in North America, it failed to take into consideration women’s distinct clinical experiences, thus rendering them all the more invisible in the statistics. Women with A I D S presented specific symptoms such as bacterial pneumonia and pelvic inflammatory disease, but these were not considered as A I D S defining. Some indicators, such as Kaposi’s sarcoma, were rarely seen in women. According to the Canadian Laboratory Centre for Disease Control, fiftythree per cent of Canadian men with A I D S in the 1980s and early 1990s presented with Kaposi’s sarcoma, but less than three per cent of Canadian women did.34 To that effect, women in A A N !, like women in A C T U P Women’s Caucuses in the United States, produced and distributed pamphlets and flyers making the definition’s gender bias more widely known and demanded that the situation be rectified. Without a diagnosis, it was more difficult for women living with A I D S to have access to treatments, obtain disability benefits, and gain access to subsidized housing and other social benefits, all of which made it easier to manage one’s health.35 An A I D S diagnosis was similarly required to participate in some clinical trials. While the C D C definition was expanded in 1987 to include two additional indicators, it was not until 1 July 1993 that the Canadian definition was revised to include pulmonary tuberculosis, recurrent bacterial pneumonia, and invasive cervical cancer, thereby allowing for a greater representation of women and other under-represented groups in A I D S diagnosis and treatment.36 The extent to which women’s activism was responsible for the change in Canada’s definition is not clear, but women’s public insistence that their clinical experiences be recognized challenged women’s invisibility in H I V and A I D S statistics.

T h e P ow e r o f I n f o r m at i o n In addition to drawing attention to women’s issues, women worked alongside men on various A A N ! committees. Like many of the men in A A N !, the women in the group tended to be white and middle class; some were H I V -negative and others were H I V -positive. Because treatment activism focused on issues such as access to experimental drugs and treatment information which were of benefit to both women and

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men, the organization was able to transcend some of the gender barriers that emerged in environments with a focus on H I V /A I D S prevention. For instance, to be effective, community-based safer sex education targeted specific audiences and used images and language accordingly, drawing heavily on constructions of masculinity, femininity, race, and sexuality. As Thomas Wendelboe makes clear in chapter 10 of this volume, messages appealing to specific audiences could elicit entirely different responses from other groups. Brochures and posters designed for gay (white) men, for example, looked considerably different than those intended for straight black women. And these distinctions, however important, proved alienating to those whose identity was not represented. Treatment activism in Ontario, while not exempt of gender-based issues, was more inclusive and less structured along identity categories of gender, race, and sexuality.37 The women who joined A A N !’s various committees with no prior experience in the women’s health movement or in the lesbian and gay liberation movement were able to draw from the experiences of those who had, and their involvement in the organization was important to their politicization. From its beginnings in early 1988, A A N ! had a press and media committee that looked after the production of the group’s quarterly newsletter, a i d s Action News! Between 1988 and 1993, close to a dozen women helped prepare the newsletter and / or reported on the group’s various public demonstrations, articulated its policy positions, reviewed promising treatments, offered criticisms of drug trials, and discussed the various obstacles to treatments. They also brought women’s issues to the attention of the newsletter’s readership. Through their contributions, they enabled others to familiarize themselves with medical and political issues affecting access to treatment and they got a sense of the social and political landscape in which their activism took place. The organization was responsible for the production of yet another type of newsletter. In their push to improve access to treatments, ac­ tivists established a treatment information network to facilitate the ­exchange of information between P H A s, health professionals, social workers, and A I D S organizations. H I V primary care physicians with large patient caseloads had difficulty staying abreast of the latest treatment information available from pre-clinical research, clinical trials, pharmaceutical companies, regulatory agencies, and medical journals.38 Although a group of H I V primary care physicians formed in Toronto in December 1987 to facilitate information sharing, physicians

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across the province struggled to remain current with the ever-expanding H I V /A I D S treatment literature. Like the physicians Wendy Mitchinson examines in chapter 11 of this volume, they lacked information about the various drug treatments available. As a result, many were reluctant to prescribe new treatments.39 To address this predicament, A A N ! set up the Treatment Information Exchange Project (T I E ). The T I E , which had twenty-five volunteers and was overseen by a steering committee of four women and six men, was charged with producing and disseminating a treatment newsletter, TreatmentUpdate / Traitement sida. The newsletter provided summaries and commentary on A I D S medical research carried out nationally and internationally and covered such things as drug dosage, drug toxicity, and possible drug interactions. It also discussed the benefits and overall effects of specific drugs and presented new developments in H I V /A I D S research. Published in both English and French at a rate of ten issues per year, TreatmentUpdate / Traitement sida proved to be an important source of Canadian-produced treatment information. In just over a year, it developed a subscription base of 700, reaching P H A s, community-based A I D S organizations, and health professionals involved in the treatment, research, and management of A I D S across the country and in the United States.40 T I E also staffed a hotline that newly diagnosed H I V -positive individuals or individuals outside of treatment information networks could call with treatmentrelated questions.41 This process of gathering and disseminating information enabled activists to develop a more comprehensive understanding of treatments available and get a clearer picture of the H I V /A I D S community across the province. The treatment access and research committee was another group within A A N ! that provided P H A s with important information about the management of their health. Its members studied drug research, licensing, and access in Canada. In December 1991, the committee produced a booklet to help people living with H I V /A I D S understand the purpose and design of clinical trials and make informed decisions about participating in them. Modelled on a publication of A I D S Treatment Resources Inc. in New York, a i d s and h i v Drug Trials in Canada: What You Need to Know also set out a series of questions to ask before joining a trial, a glossary of terms, and a list of treatment information centres in  the United States and Canada.42 Feedback on draft copies of the booklet was obtained from such groups as the Canadian A I D S Society, the Community Research Initiative of Toronto, the Pharmaceutical Manufacturers Association of Canada, and the Canadian H I V Clinical

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Trials Network. Through such activities, members developed relationships with others involved in treatment access and research, acquired and shared important treatment-related knowledge, and developed tools to empower P H A s interacting with the health-care system.

A Voice of Their Own By the late 1980s and early 1990s, a diversity of identity-based A I D S service organizations emerged within the Ontario H I V /A I D S movement to meet the growing needs of communities affected by H I V /A I D S . Organizations such as the Black Coalition for A I D S Prevention, the South Asian A I D S Coalition, and the Prisoners’ H I V /A I D S Support Action Network joined the A I D S Committee of Toronto (A C T ), the province’s first and largest A I D S service organization, in offering targeted education, prevention, and support services. Although A C T ’s membership was open to anyone and it offered a broad array of services, its founding roots were in the lesbian and gay community and many of its services were directed to those most affected by the epidemic – men who have sex with men. When A C T created the Women and A I D S Project in January 1989 in response to the growing numbers of women diagnosed with H I V in the city, women seeking services felt a dis­connect between their concerns and those of A C T ’s male clients.43 Moreover, like some of the people working at A C T at the time, some H I V -positive women began to question the role of H I V -negative people within the organization. Darien Taylor participated in A C T ’s support group for H I V -positive women for about a year and recalls that while her experiences with the group were initially positive, the group offered women little in terms of empowerment. “The group,” she notes, “felt very isolated from concerns in the larger H I V community, and I was beginning to question the fact that [it] was led by women who were not H I V positive.”44 Taylor eventually left the support group and joined A A N !, where she became involved in a variety of treatment advocacy issues that resonated with her. With the encouragement of Andrea Rudd, who briefly attended the support group and also became active in A A N !, the two women secured a Canada Council grant and started working on an anthology of works by women living with H I V /A I D S . Rudd had previously travelled to London, England, where she visited the offices of the self-help group Positively Women, an organization run by and for H I V positive women, and felt inspired by the experience. While seeking additional sources of funding for the anthology, the women seized a

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funding opportunity to establish a provincial A I D S service organization for women. Rudd and Taylor founded Voices of Positive Women (V O P W ) in 1991 and, like Positively Women, it was run by and for ­positive women. The creation of V O P W signalled the development of a collective identity based in women’s embodied and social experiences of H I V /A I D S and positive women’s need for community within the wider H I V /A I D S movement. In a small office that A A N ! activist Anne Nenarokoff described as being decorated with “a woman’s touch,”45 V O P W offered women a space where they could meet and share with one another. The pervasive stigma surrounding H I V , concerns over having to disclose how one became infected, and fear of losing custody of one’s children are some of the reasons that prevented many newly diagnosed women from reaching out to family and friends. Unless they were part of a healing circle or a support group that included other women, few H I V positive women knew other positive women with whom they could discuss their experiences and specific health concerns. Unlike positive gay men, they felt they had no community to turn to. Taylor observed in 1990 that the informal grapevine of treatment information and personal anecdotes had proved to be an important survival strategy for gay men. Although it was haphazard and sometimes inaccurate, it seemed to her that it succeeded in enhancing and extending the lives of H I V positive gay men. Positive women who did not necessarily socialize with gay men or who were not situated within the larger H I V /A I D S community were often excluded from this network of information.46 Louise Binder joined a V O P W support group upon learning of her positive diagnosis in 1993 and recalls, “It was the first time where I got a chance to touch and feel with other positive women and there’s just nothing like that. Some of them had been H I V -positive for quite a long time and were still alive which was sort of contrary to the advice I was getting so it was really important to listen to those women and get strength from those women.”47 The creation of a space for positive women, then, helped women overcome their sense of isolation and it facilitated the development of a community where women could discuss topics such as symptoms, H I V disclosure, reproductive rights, treatments, and health care practitioners. The women who came together in the organization’s early years drew on their experiences of H I V /A I D S , they consulted the A C T U P Women’s Caucus’ Women and a i d s Handbook, published in March 1989, and they looked to various groups, including A C T and A A N !, for

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direction.48 They fashioned the organization on a self-help model and produced materials that addressed women’s specific information needs. “I always considered that I worked hard to inform myself about H I V ,” recalls Taylor, “yet … I spent months lying night after night in my big Victorian bathtub, looking for Kaposi’s sarcoma lesions on my body. I had no information to tell me that these lesions, though common in H I V -positive men, occur very rarely in H I V -positive women.”49 Since most of the printed materials addressing women and H I V /A I D S in the late 1980s were on the topic of prevention, V O P W produced a series of pamphlets explicitly for positive women. These covered subjects such as health, pregnancy, birth and breast-feeding, and research. They were produced in English and French and were distributed by the thousands in Canada, the United States, and overseas.50 V O P W also produced a newsletter that covered the organization’s activities, women’s healing experiences, their experiences as caretakers and / or single mothers, A I D S conferences, and a variety of other subjects. It connected women across the province and fostered a sense of community among women who often shared little in common other than their H I V status. Oc­ casionally, an insert titled Treatment Issues for Women Living with h i v and a i d s that discussed topics such as the human papillomavirus and candidiasis was added to the newsletter. Disseminating information on treatment options was one way the organization sought to empower women to take control of their lives and make informed choices that were right for them.51 Most women in the province could trace their infection to heterosexual contacts. Between 1985 and 1996, 761 women (or 48.3 per cent) of women diagnosed during this period were exposed to the virus through sex with a man, 325 women (or 20.6 per cent) were exposed through injection drug use, 313 women (or 19.9 per cent) came from countries where H I V was endemic, and 167 women (or 10.6 per cent) were exposed through blood or blood products.52 V O P W members came from all walks of life and had varied life experiences, but in its formative years, members were mostly white and middle class.53 Writing in 1992, activist Anne Nenarokoff wrote, “Most women are not ‘political’ the way members of the gay male community are. Women have a difficult time making their needs known, seeking information, and even support.”54 Building on observed and expressed challenges, V O P W worked to foster and nurture positive women’s leadership skills. For ­example, it offered a public speaking and presentation skills workshop so that members could learn to talk with confidence at public events,

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present women’s issues, and advocate for women’s needs. These workshops also sought to develop skills and knowledge for women to par­ ticipate more effectively in their organization and in the broader H I V /A I D S community.55 When women wished to implement ideas, V O P W offered them their support. Shari Margolese learned that she was H I V -positive shortly after giving birth to her son. With the help of V O P W and another local group, she established an H I V -positive mothers’ support group where participants could focus on family issues such as disclosure to children, disclosure to schools, guardianship, and caring for the family when one or more members are not feeling well.56 Some members who first turned to V O P W for support and services became active in a variety of other H I V /A I D S committees and organizations, including the Canadian A I D S Society, the Canadian H I V Trial Network, the Community A I D S Treatment Information Exchange, the Canadian Treatment Action Council, the Ontario A I D S Network, and the Community Research Initiative of Toronto. Through their participation in these and other bodies, they helped ensure that women’s ­voices were represented, that their issues were addressed, and that women throughout the province were informed of important developments in the H I V /A I D S community.

Taking Care of Women’s Health Access to treatments and health care was an important challenge for a number of H I V -positive women. Positive women who participated in community-based research reported having a difficult time making ends meet.57 By 1992, the provincial government covered the costs of three antiretroviral drugs – zidovudine (A Z T ), dideoxyinosine (dd I ), and dideoxycytidine (dd C ) – and drugs such as aerosol pentamidine for the prophylaxis of P C P , but other treatments were not provincially covered. While some P H A s had access to drug coverage under private insurance plans, coverage was not always comprehensive and some copayment schemes restricted what drugs one could afford to take.58 Twenty-two out of thirty-four women in Ontario who answered a questionnaire for women living with H I V /A I D S (sixty-five per cent) said they obtained their treatments, both medical and other types, by paying out of pocket.59 Considering that women generally earned less income than men, women’s ability to take care and control of their health was often dictated by the financial resources available to them.60 Women with family and childcare responsibilities also tended to put the needs

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of others before their own. Some missed medical appointments to care for a partner or a child; others did not adhere to their treatment plan so that they could avoid adverse side effects of drugs that could prevent them from taking care of their families.61 A number of women expressed scepticism about pharmaceutical drugs and preferred natural treatments in the management of their health. These included a combination of various approaches, including homeopathy, nutritional supplementation, acupuncture, exercise, meditation, and massage therapy. Some women were opposed to using antiretroviral drugs on the grounds that these were tested on men and that little was known about their effects (metabolism, toxicity, and efficacy) in women’s bodies.62 Although vitamins, minerals, and supplements were believed to help maintain health, their cost was an oft-cited reason positive women did not include them or stopped including them in their health regime.63 In the summer of 1993, V O P W started to offer its members vitamins and other supplements at cost to help women expand their treatment plan. The following year, with the help of a donation from comedian Sandra Shamas, Andrea Rudd and two other members built on the idea and set up a treatment fund. The fund provided members throughout Ontario with a basic renewable two-month nutritional supplement package or up to $35 every two months toward expenses such as visits to naturopaths, acupuncturists, or other healthcare providers. By the end of its first year, seventy-six women were using the fund.64 Through fundraising efforts, members of the treatment fund committee were able to increase the size of the supplement ­package and raise the reimbursement for treatment expenses to $55 in  January 1995.65 V O P W also offered members health maintenance workshops on topics such as relaxation and creative visualization, naturopathic medicine, and aromatherapy.66 Another way in which V O P W advocated for the treatment needs of women living with H I V /A I D S was by documenting women’s illness experiences, the therapies they were using, and their encounters with health-care providers. As with other life-threatening diseases affecting both men and women, biomedical research has focused mostly on men’s experiences.67 Early in 1993, Linda Gardner of the Regional Women’s Health Centre and Darien Taylor of V O P W met to discuss the treatment needs of women living with H I V /A I D S in Ontario. The two  women had worked together on the A A N ! treatment access and research committee. With four other women, two of them doctors at the  Immunodeficiency Clinic of the Toronto General Hospital, they

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organized an all-day forum between HIV-positive women and physicians. The organizers hoped that by bringing these two groups together, they could “reach a large group of H I V + women and produce ground-breaking information about the health care needs of women living with H I V in Ontario.”68 That year, forty H I V -positive women and twenty physicians attended the forum, providing participants with the opportunity to ask each other questions, share concerns about clinical / treatment issues, and address social / advocacy issues specific to women. At the end of the day, participants had a greater understanding of the various barriers women faced in accessing treatment and care, and organizers were able to formulate directed recommendations to a variety of bodies, including community-based A I D S organizations, government departments, medical professional associations and societies, and orga­ nizations involved in HIV-related research, so that they could be more responsive to positive women’s needs.69 Complementary therapy and anti­viral treatment choices and issues were the focus of subsequent allday forums. These endeavours, along with other research conducted by members, filled an important information gap in knowledge about women’s gendered and embodied experiences of H I V /A I D S .

Conclusion The early construction of H I V /A I D S as a gay men’s disease and H I V / A I D S ’ subsequent association with risk groups obscured women’s sexual vulnerability to H I V and left many H I V -positive women without timely and adequate treatments and services. A I D S activists involved with A A N ! undertook a number of actions to inform the public, the medical profession, the scientific community, and governments of the fact that H I V /A I D S was a women’s issue. They denounced biomedical research that studied H I V -positive women solely in relation to their ability to bear children. They demanded that H I V -positive women’s differential symptoms be recognized in the A I D S case definition. And they challenged misleading representations of women’s sexuality in H I V /A I D S discourse. Women involved in AAN! who were HIV-positive developed a collective identity based on their embodied and social experiences of H I V /A I D S . They used this identity to reach out to other positive women in search of community and created VOPW. Members embraced a self-help model of health care as a means of ensuring greater and more meaningful ­participation in the management of their health. Largely invisible in

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biomedical research, they produced and shared knowledge about their symptoms, illnesses, and therapies. They presented their issues and the various barriers they encountered as women, wives, and mothers trying to access treatments and services to key bodies in the hopes of making the health-care system more responsive to their needs. They also created opportunities for women to network and overcome some of the isolation and discrimination they faced as a result of their positive diagnosis. Ron Foley noted in an A I D S treatment needs assessment conducted in 1991 for the Community A I D S Treatment Information Exchange that P H A s involved in their treatment programs represent an elite, “for they have the ability, the initiative and the confidence to seek out and decipher information as an important step in the process of making informed treatment decisions.”70 The women involved with V O P W in its formative years were no different. Not all women could participate in the H I V /A I D S movement equally and benefit from the support or knowledge gained through activism. Women’s participation in the H I V /A I D S movement in Ontario was limited by a number of factors, including their health, their financial resources, their family and domestic responsibilities, their education, and their geographical location in the province. Taken together, these barriers to participation add to the multiplicity of ways in which women’s experiences of H I V /A I D S differed from men’s.

Acknowledgments I thank the women who met with me to discuss their experiences within the H I V /A I D S movement; the participants in the Gender and Health Histories Symposium for insightful discussions about gender and health; the Social Sciences and Humanities Research Council for financial support; and finally, Marc Stein, Peter Stevens, Colin Bhattacharjee, members of York University’s Gender Reading Group, and the editors of this volume for feedback on earlier versions of this paper.

notes   1  Opportunistic infections are infections that occur in people with compromised immune systems that would otherwise not develop were the immune system not affected. For examples of terms used in the mainstream press, see “‘Lèpre gaie’ à Montréal,” La Presse, 20 July 1982, C11; “Deux Montréalais meurent d’une maladie appelée ‘la peste gaie,’” Le Devoir,

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21 July 1982, 10; “Gay cancer confirmed,” Globe and Mail, 21 July 1982, 9; “La ‘peste gaie’; une panique inutile?” La Presse, 24 July 1982, A18; “Gay disease treated in B.C.,” Globe and Mail, 29 July 1982, 8. Despite using terms such as “gay plague,” Toronto Star and Montreal Gazette articles did note that while A I D S mostly affected gay men, cases had been diagnosed among straight men and women. See “Gays’ Death: Mystery Condition Makes Germs Killers,” Montreal Gazette, 10 December 1981, 41; “‘Gay Plague’ spreads in the U.S., M.D. says,” Toronto Star, 15 July 1982, A5; “‘Gay plague’ kills 5 blacks,’” Montreal Gazette, 4 September 1982, A1; Lillian Newberry, “‘Gay Plague’ Has Arrived in Canada,” Toronto Star, 26 November 1982, C2l; Marilyn Dunlop, “Baffling killer disease attacks mostly homosexuals, drug users,” Toronto Star, 25 August 1982, D16; Marilyn Dunlop, “Atlanta Diseases Detectives Hot on Trail of ‘Gay Plague,’” Toronto Star, 28 November 1982, D12.   2  US Centers for Disease Control, “Epidemiologic Notes and Reports Immunodeficiency among Female Sexual Partners of Males with Acquired Immune Deficiency Syndrome (A I D S ) – New York,” Morbidity and Mortality Weekly Report 31, no. 52 (7 January 1983): 697–8; Anne Quinn, “Classification of A I D S Patients in Canada,” Canada Diseases Weekly Report 11–27 (6 July 1985): 113. While reports of A I D S among women in Canada first appeared in the 30 July 1983 issue of Canada Diseases Weekly Report, an article earlier that year discussed the symptoms of an infant with A I D S , noting only that its mother had lymphoma four days after delivery, that she subsequently developed tuberculosis, and that she died six weeks later. See J.H. Joncas, “Acquired (or Congenital) Immune Deficiency Syndrome (A I D S ) in Infants Born of Haitian Mothers – Quebec,” Canada Diseases Weekly Report 9-4 (22 January 1983): 13.   3  See Patton, “With Champagne and Roses,” 165–87; Treichler, “A I D S , Gender, and Biomedical Discourse,” 190–265.   4  Lisa Freedman, “A I D S Affects Us,” Healthsharing 5, 1 (Winter 1983): 8.  5 Canada, Le v i h au Canada, 6.   6  See Brier, “Locating Lesbian and Feminist Responses to A I D S ,” 234–48; Schneider and Stoller, Women Resisting a i d s .  7 See Brier, Infectious Ideas; Gould, Moving Politics; Epstein, Impure Science.  8 See Manthorne, Canadian Women and a i d s ; Lindquist and Rayside, “Canada: Community Activism, Federalism, and the New Politics of Disease,” David M. Rayside and Evert A. Linquist, “Canada: Community Activism, Federalism, and the New Politics of Disease,” in a i d s in the Industrialized Democracies: Passions, Politics and Policies, edited by David L.

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Kirp and Ronald Bayer, 49–98 (Montreal: McGill-Queen’s University Press, 1992); Lavoie, “Deux solitudes,” 337–62; Brown, Replacing Citizenship; Silversides, a i d s Activist.  9 See Kinsman, The Regulation of Desire; Warner, Never Going Back; Ross, The House that Jill Built. 10  Michael Lynch, cited by Glenn Wheeler, “Advocacy Action on A I D S ,” Now, 28 January 1988 – 3 February 1988, 20. 11  When a clinical trial for A Z T was set up in Ontario in 1987, sixty-seven people with A I D S were enrolled, thereby granting participants access to A Z T before its legal release in Canada. There were, however, close to 2,000 people known to be H I V -positive in the province at the time. To gain access to the promising drug, anxious P H A s who had the energy and money began travelling to Buffalo and other US locations to obtain the new treatment. See Robert Remis, Carol Swantee, Kirsten Rottensten, Lorraine Schiedel, Maraki Fikre Merid, Report on h i v /a i d s in Ontario 2002 (University of Toronto, November 2003), Table 1; Canadian Lesbian and Gay Archives, hereafter C L G A , Tim McCaskell, Box 7.6.3 93-006/06, Consensus Conference 1 and 2 December 1988; Anita Rachlis, “The Experience of A Z T Distribution in Ontario as a Possible Model of Distribution for Other Drugs,” in Ontario Ministry of Health Working Conference on a i d s and h i v Infection – Rapid Access to Safe and Effective Therapy – A Discussion Paper, 16; Ken Popert, “P W A ’s Head South for A Z T ,” Body Politic, November 1986, 15. P H A s also travelled to the United States for other drugs unavailable in Canada. See, for example, “Not My Department,” Xtra!, 11 December 1987, 16. 12  C L G A , Glen Brown, Box 7.6.2 93-006, “A A N ! Where We Came From, What We Did.” 13  C L G A , C A N 2311, Health and Welfare Canada, “Drugs for the Treatment of A I D S ,” Issues, 8 February 1989. 14  Lillian Newbery, “Ottawa Asks Two Firms to Test Drug On A I D S Symptoms,” Toronto Star, 12 January 1988, A15. 15  See Canadian Press, “Ottawa is Criticized Over A I D S Drug Delay,” Globe and Mail, 5 January 1988, A19. 16  Kelly Toughill, “Ottawa Changes Rules for A I D S Drug,” Toronto Star, 10 February 1989, A22. 17  Glen Wheeler, “Inaccessible Drug Therapies Infuriate People with A I D S ,” NOW, 11–24 August 1988, 11. 18  Michele Brill-Edwards, cited by David Adkin, “Victory for Life,” Xtra!, 10 February 1989, 3.

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19  Mark Nichols, “An Abrupt Reversal: People with A I D S Can Get Untested Drugs,” Maclean’s 102, no. 11 (13 March 1989), 49. 20  Before joining A I D S A C T I O N N O W !, Mary Louise Adams noted in articles for Rites that both lesbians and gay men were affected by the media-­ inspired A I D S hysteria and that both had much to gain by working together on this “common cause.” See Mary Louise Adams, “Women Talk about A I D S ,” Rites, July–August 1984, 9, and Mary Louise Adams, “Pushing Common Cause: Notes on Lesbian and Gay Coalition, Safer Sex and Women,” Rites, July–August 1984, 10–11. 21  Alison M. Kim, Candace M. Tingen, and Teresa K. Woodruff, “Sex Bias in Trials and Treatment Must End,” Nature 645 (10 June 2010), 688. 22  Dialogue: h i v Positive Women in Ontario and Their Doctors (Toronto: Regional Women’s Health Centre, 1993), 15; A I D S A C T I O N N O W !, “Women and Testing A I D S ,” Testing a i d s , May 1989, 3. See Karin Donnan, “Women and A I D S : A Personal Perspective,” a i d s Action News!, issue 12 (December 1990), 1–2; Anne Nenarokoff, “Voices of Positive Women,” a i d s Action News!, issue 16 (Summer 1992), 3. Several H I V -positive women reported that their sexual partners were bisexual. In their report on H I V /A I D S in Ontario, Robert Remis et al. indicated that of the 8,221 men who had sex with men who were diagnosed H I V -positive between 1985 and 2002, 19.4 per cent indicated that they were bisexual. See Robert Remis et al., Report on h i v /a i d s in Ontario, November 2003, 11. 23  Ron Foley, a i d s Treatment Information Needs Assessment, Canadian A I D S Treatment Information Exchange, September 1991, 18. See also Dialogue: h i v Positive Women and Their Doctors, 38. The notion of risk behaviours as opposed to risk groups started gaining favour sometime in 1987. See Philip Berger, Transcript of Hearings, Krever Commission of Inquiry on the Blood System in Canada, vol. 16 (14 March 1994), 2934. 24 See C L G A , Glen Brown, Box 7.6.2 93-006, loose papers 1, “Women Get A.I.D.S.” (undated flyer); C L G A , Glen Brown, Box 7.6.2 93-006, loose ­papers 2, Pamphlet “Q: What Do Sexism, Racism, Poverty, Homophobia, Reproductive Rights, Access to Health Care, Marginalization Have in Common?;” “Women and Testing A I D S ,” Testing a i d s , 3; and C L G A , A I D S A C T I O N N O W !, Box 7.6.2 1993-006/01, “This A I D S Pamphlet Is About Women.” 25  C L G A , A I D S A C T I O N N O W ! vertical files, C A N 2311, “A A N ! Presents an A I D S Activism Teach-In Sunday, May 7 1989;” C L G A , Glen Brown, Box 7.6.2 93-006, loose papers 1, “Teach-In Schedule.”

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26  C L G A , Glen Brown, Box 7.6.2 93-006, Réaction Sida, “Briefing of Montreal A I D S Conference (and Criticisms) by Réaction S I D A to A A N ! and A C T U P .” 27  Mary Louise Adams, “Montreal A I D S Conference,” Healthsharing 11, no. 1 (Winter 1989), 6. Valerie Scott, a member of the Canadian Organization for the Rights of Prostitutes, was one of many sex workers present at the conference protesting the image of sex workers as vectors of infection as opposed to that of safer sex promoters and educators. See New York Public Library Humanities and Social Sciences Library, A I D S Activist Videotape Collection, 1983–2000, Catherine Gund, Video 01103-A “Montreal A I D S Conference #2, 1989, June.” 28 Patton, Last Served, 12. See also “Women and A I D S : An Interview with Isabelle Sourdif,” Health Promotion (Summer 1990): 6. 29 See Dialogue: h i v Positive Women in Ontario and Their Doctors, 47. 30  Theresa Dobko, “International Working Group on Women and A I D S Conference: Less Talk, More Care for Women Needed,” Kinesis (September 1989): 9. 31  Catherine Hankins and Margaret Handley, “H I V Disease and A I D S in Women: Current Knowledge and a Research Agenda,” Journal of Acquired Immune Deficiency Syndromes 5, no. 10 (1992): 965–6. 32  Brent Southim, “World A I D S Day Demo,” a i d s Action News!, issues no. 8 and 9 (Winter 1990), 4. 33  Maureen Murray, “Protesters Hold ‘Die-In’ over A I D S ,” Toronto Star, 2 December 1990, A10. 34  Cameron Johnston, “Many Canadians Unaware of A I D S ’ Impact on Women,” Canadian Medical Association Journal 150, no. 2 (15 January 1994), 248. In 1990, Catherine Hankins noted that Kaposi’s sarcoma was observed in 2.1 per cent of women living with A I D S . See Catherine Hankins, “Women and H I V Infection and A I D S in Canada: Should We Worry?” Canadian Medical Association Journal 143, no. 11 (1990), 1172. 35  Tim McCaskell, “A I D S , What’s In a Name?,” a i d s Action News!, issue 19 (Fall 1993): 4. 36  “Revision of the Surveillance Case Definition for A I D S in Canada,” Canada Communicable Disease Report 19 (1993): 19, 116–17, 196–7, in Canadian Medical Association Journal 150, no. 4 (15 February 1994): 531–4; Meghan O’Connell, “Women … and A I D S ,” One Voice (Summer’s Start 1992), 6; Remis et al., Report on h i v /a i d s in Ontario 2002, 24. 37  Darien Taylor (co-founder, Voices of Positive Women), interview by author, Toronto, 23 April 2007.

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38  According to a discussion paper for the Ontario Ministry of Health Working Conference on A I D S , there were, in 1988, some twenty-five ­community-based A I D S physicians providing primary care to people living with H I V /A I D S in Toronto, each physician seeing between fifty and 250 patients, most seeing over 100. See C L G A , Tim McCaskell, Box 7.6.3 93-006/06, Consensus Conference 1 and 2 December 1988, “Communitybased and Institutional Care: Integration, Coordination and Professional Education” (November 1988), 3. In addition to providing treatment to P H A s, physicians caring for P H A s considered their patients’ psycho-social needs as well, which, in addition to the paperwork involved in requesting experimental treatments, contributed to a heavier workload. 39  Philip Berger, Transcript of Hearings, Krever Commission of Inquiry on the Blood System in Canada, vol. 83 (11 October 1994), 17981; C L G A , Tim McCaskell, Box 7.6.3 93-006/05, Treatment Registry, Canadian A I D S Society, Treatment Issues: Submission by the Canadian a i d s Society to the Parliamentary Ad-hoc Committee on a i d s (24 April 1990). 40 See C L G A , Tim McCaskell, Box 7.6.3 93-006/05 A A N ! Steering Committee 14 August 1990, “Section I – The A I D S Action Now! Treatment Information Exchange Project;” C L G A , Tim McCaskell, Box 7.6.3 93-006/05 A A N Steering Committee 11 October 1988 – 9 May 1989, “A A N ! Steering Committee Meeting, 24 January 1989;” Eric Mitchell, “T I E Project Underway,” A I D S Action News!, issues 8 and 9 (Winter 1990), 11. 41  Anne Nenarokoff, “Treatment Information Exchange: New Health Promotion Programme,” a i d s Action News!, issue 12 (December 1990): 12. In 1991, T I E became the Community A I D S Treatment Information Exchange, an independent charitable organization known today under the name Canadian A I D S Treatment Information Exchange, which also acts as a source of information about hepatitis C. 42  C L G A , Glen Brown, Box 7.6.2 93-006, T A A R Committee: minutes, cor­ respondence, etc., April 19 91 – November 1991, media release, 29 November 1991, “A I D S A C T I O N N O W ! Publishes Booklet on Clinical Trials;” C L G A , Glen Brown, Box 7.6.2 93-006, T A A R Committee: minutes, correspondence, etc., April 1991– November 1991 “A I D S and H I V Drug Trials; What You Need to Know.” Such information was important because in some cases, entering a trial was the only way for people living with H I V /A I D S to access experimental treatments. 43  Andrea Rudd (co-founder, Voices of Positive Women), interview with author, Toronto, 23 February 2007; Taylor, interview with author. 44  Rudd and Taylor, Positive Women, 11.

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45 Ibid. 46 Ibid. 47  Louise Binder (member, Voices of Positive Women), interview with author, Toronto, 9 April 2007. 48  Taylor, interview with author. 49  Rudd and Taylor, Positive Women, 14. 50  Darien Taylor, “A Review of Our Achievements 1991–93,” Voices: A Newsletter for Women Living with h i v /a i d s 2, no.3 (November 1993): 2–3. 51  Louise Binder in “The Divine Secrets of the + Sisterhood: Treatment Information for Women Living with H I V /A I D S ,” The Positive Side 6, issue 2 (Spring 2003): 24. 52  Remis, “H I V /A I D S ,” 41. Remis notes that seven women (or 0.4 per cent) were exposed to H I V through needle stick, acupuncture, or tattoo. 53  Laurette Lévy (member, Voices of Positive Women), interview with author, Montreal, 12 February 2008. 54  Nenarokoff, “Voices of Positive Women,” 3. 55  See Taylor, “A Review of Our Achievements 1991–93,” 2. 56  Shari Margolese (member, Voices of Positive Women), personal papers, letter from Louise Binder, Chair, Voices of Positive Women, to the scholarship program coordinator, XI International Conference on A I D S Secretariat, 17 October 1995. 57  Laurette Lévy (member, Voices of Positive Women), personal papers, Laurette Lévy, Ron Foley, Sarah Forer, Taking Care of our Health: A Study of Women Living with h i v /a i d s and the Treatments They Use, (Voices of Positive Women, December 1994), 29; Dialogue III: Current Antiviral Treatment Choices and Issues in Decision Making (Toronto: Regional Women’s Health Centre, 1997): 14. 58 Many P H A s, unable to afford the cost of drugs, faced the difficult decision of leaving their jobs to access treatment through the Ontario Drug Benefit plan, a plan offering some drugs free of charge to people receiving social assistance. For the cost of treatment for people living with H I V /A I D S in 1999, see Richard Elliott, Controlling Drug Costs for People Living with h i v /a i d s (Montreal: Canadian H I V /A I D S Legal Network, 2004): 3. 59  Dialogue: h i v Positive Women in Ontario and Their Doctors, 22. 60  See Statistics Canada, Income and Labour Dynamics Section, Income Statistics Division, Earnings of Men and Women, 1997 (Ottawa : Minister of Industry, 1999). 61  Dialogue III, 15; Jacqueline C. Gahagan and Charlotte J. Loppie, “Counting Pills or Counting on Pills? What H I V + Women Have to Say

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about Antiretroviral Therapy,” Canadian Woman Studies 21, issue 2 (Summer / Fall 2001): 119. 62  Lévy et al., Taking Care of our Health, 32; Campbell, Women, Families and h i v /a i d s , 100. 63  Lévy et al., Taking Care of our Health, 16. 64  “Voices’ Committees,” Voices of Positive Women: A Newsletter for Women Living with h i v /a i d s 3, no. 3 (December 1994): 2. 65  “Treatment Fund Update,” Voices of Positive Women: A Newsletter for Women Living with h i v /a i d s 3, no. 3 (December 1994): 5. 66  “Health Maintenance Workshops,” Voices of Positive Women: A Newsletter for Women Living with h i v /a i d s 3, no. 2 (July 1994): 7. 67  Bird and Rieker, “Gender Matters: An Integrated Model for Understanding Men’s and Women’s Health,” 746. As Bird and Rieker note, the study of women’s health experiences is often limited to sex-­ specific diseases and disorders such as breast cancer. 68  Dialogue: h i v Positive Women in Ontario and Their Doctors, 9. 69  Ibid., 49–54. 70  Ron Foley, a i d s Treatment Information Needs Assessment (Toronto: Com­ munity A I D S Treatment Information Exchange, September 1991): 6.

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Section Three

Authority and Ideals

This section complicates our understanding of health by exploring the ways that wider societal discourses prescribe certain norms and values for citizens. In doing so, the chapters in this section raise questions about the authority of medicine today, the power of patients to exercise their agency over how their health is defined, and the ways that an increasing focus on consumer capitalism in the Western world shapes our understanding of what it means to be healthy by identifying lifestyles and behaviours that allow us to live up to the norm in different time periods. These norms and values serve to identify health by pointing to markers of illness in others, identified as abnormality / deviance. One example of marking difference can be observed in the ways that the definition of healthy children extended in 1950s suburban Canada beyond the physical to incorporate psychological markers of heterosexuality. The first chapter of this section explores how this allowed for the identification of adolescents who were abnormal. Health, in this instance, allowed children who resisted heteronormative ideals to be identified, which served to stigmatize them while at the same time enforcing the authority of the social workers whose job it was to categorize them. This points to the ways that medical authority was adopted and employed by other professionals. Similarly, other discourses appropriated medical science to reinforce heteronormative constructions of health. For instance, in health and hygiene advertisements in Playboy and Esquire magazines in Cold War America, advertisers used the language of health and hetero- and hyper-male sexuality to encourage the consumption by men of hygiene and ­toiletry products. This points to the power of consumer culture in marketing a particular healthy norm (heterosexuality) while

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identifying the other (homosexuality) – men who did not conform to the prescriptions for healthy masculinity. The desire for patients to conform to advertisers’ prescriptions for ideal bodies is also explored in the case of those who are overweight. The ways in which pharmaceutical companies aimed to educate doctors about methods of treating obesity, a condition that became a ­significant focus of concern in post-war Canada, is explored. To sell products, the companies built on the idea that the slender body was a healthy body. In doing so, they appealed to popular cultural conceptions of the roles of men and women and their different relationships to food. In this work, a new authority is identified – that of the pharmaceutical companies, who forged an important relationship with ­doctors in the last half of the twentieth century. The power of drug companies to influence the medical profession is particularly significant in the exploration of postpartum depression. Pharmaceutical companies sought to design a drug regime that would create the ideal mother. Postpartum depression presented an “extreme contradiction” in the face of normative gender roles as the women who suffered from this illness did so “because of motherhood.” The ways that psychology recast women’s biological citizenship to emphasize their role as wives and mothers is examined. As postpartum depression contradicted normative ideals of motherhood, women who suffered from the condition needed to be “fixed” to live up to the ideals. The need to live up to societal ideals of health is explored in a discussion of cosmetic surgery in twentieth-century Canada. The complex role of the physical and psychological in cosmetic surgery is teased out in this chapter, where a person’s experience of enhanced health might be reliant on a certain bodily esthetic that was connected to broader societal expectations for women and men in different time periods. Surgery, at times, was employed to repair defects in the “unhealthy” and, at other times, to enhance already “healthy” bodies. This chapter problematizes the ways that health and normality are entwined in different periods and the ways that gender and health are inextricably linked. All of the chapters in this section point to the complex interplay of factors that influence what it means to be healthy in different times and places, and the ways that gender is embedded in the culture in which the medical profession and, increasingly, other wielders of ­authority, define normal.

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9 Referred for Special Services: Children, Youth, and the Production of Heteronormativity at Alexandra Neighbourhood House in Post-war Vancouver Anika Stafford and Mona Gleason Alexandra Neighbourhood House (A N H ) in Vancouver, British Columbia, began to run age-based programs for children and young teenagers referred to them by various social services in the community in the 1920s. By the 1940s, these programs also had strong ties with the University of British Columbia’s School of Social Work. Staff, including social work students who were placed at A N H for practicum experience, had extensive discussions about the youngsters enrolled and often drew up reports based on their observations of individual participants. In these reports, social workers were particularly preoccupied with the gender roles and sexual identity of the youngsters they observed. Such concern over the proper heterosexual development of young people was in keeping with the trend toward the inclusion of psychological “normalcy” within definitions of health in the post-war period in Canada.1 How, we ask in this chapter, did social workers in the context of community centre programming at A N H encourage children’s future heterosexuality by pathologizing those participants, particularly but not exclusively girls, who acted against the gender and sexuality norms of the post-war period? Our focus is on the role that social workers played in ensuring, or at least encouraging, children’s future heterosexuality as part and parcel of definitions of healthy post-war citizenship.2 This chapter then engages with a number of themes running through

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this collection, particularly normalization, gender, and the family as they relate to health and healthy living. It also speaks to the importance of gender and sexuality in the cultivation of citizenship among the ­children with whom social workers interacted at A N H . As Thomas Wendelboe does in chapter 10 in this volume, we examine the post-war fear of homosexuality. Our focus, however, is on the role that experts, particularly social workers, played in ensuring, or at least encouraging, children’s future heterosexuality. This chapter also complements others within this collection that focus on gender norms, citizenship, and belonging within broader debates about health, such as Catherine Gidney’s analysis of monitoring weight as a measure of university students’ psychiatric health (see chapter 4) and Patricia Reeve’s examination of health discourse with respect to workingmen in antebellum United States (see chapter 1). Adult efforts to promote rigidly gendered heterosexuality as a part of “normal” and healthy childhood remain underexamined in Canadian history, as does the connection of these efforts to post-war ideas about social acceptability and democratic citizenship.3 An important contribution remains Mary Louise Adams’ study of the efforts of educators, social workers, psychologists, and other professionals to ensure that older teenagers cultivated socially acceptable (i.e., heterosexual) attitudes toward dating, marriage, and sex. Paralleling Adams’ work, Mona Gleason has shown how psychology influenced parenting advice in the post-war period made powerful equations between traditional gender roles and healthy normality in both childhood and adulthood.4 Although she does not focus on children, Elise Chenier has very profitably explored how the inclusion of sexual deviance in an increasingly complex lexicon of medical, legal, psychiatric, and psychological treatment legitimized the suppression of non-heterosexual identities as a key feature of citizenship and welfare state expansion in Canada, particularly after the war.5 This chapter contributes to this historiography, underscoring how heteronormativity was policed and enforced in the lives of young Canadians. A close reading of selected A N H records written by social workers suggests that they drew upon two overarching gendered discourses that worked in tandem to promote heteronormative social relations: the promotion of heterosexuality and gender normativity, and the pathologization and psychologization of same-sex attractions and gender variance. Social workers praised gender conformity as evidence of proper

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psychological adjustment, ability to get along with others, healthy citizenship, and positive social belonging. In contrast, they problematized gender non-conformity in school-aged children and younger teenagers – not just older teens – as pathological and “abnormal,” characterizing it as an inability to socialize appropriately and marking a significant threat to a healthy, happy, “normal” future. While norms around gender and sexuality are portrayed as “natural” in the ANH files, they are, paradoxically, tightly policed and encouraged by the professionals working with children at A N H . While we focus primarily on professional adult perspectives, our critique aims nevertheless to bring legitimacy to the lives of youngsters who were judged to contravene gender boundaries.

The Records of Alexandra Neighbourhood House and the Provision of “Special Services” The primary source data for this chapter are a series of restricted A N H records housed at the City of Vancouver Archives. The records consist of descriptions of A N H programs for children and reports of individual children by social workers and occasionally psychologists or psychiatrists. Some of these reports formed the basis of recommendations for what social workers referred to as “Special Services” for particular children. Special Services described both a group of professionals and a process. In the reports, it was shorthand for the closer scrutiny of ­children by a team of psychiatrists, psychologists, and social workers and  involved home visits and psychiatric evaluations. Girls exhibiting behaviours deemed inappropriately masculine and boys considered inappropriately feminine, for example, were referred for Special ­ Services at A N H and it is these referrals that are of particular interest in this chapter. Although reports regarding boys reinforced the equation between socalled good development and white, heterosexual, able-bodied norms for masculinity, far more reports exist that targeted girls. We therefore focus primarily on how gender was monitored in girls to ensure particular normative development. While the records are an important source of information about the discursive construction of gendered and sexualized identities in youngsters in a growing Canadian city after the Second World War, they have considerable analytical limitations. The role of race, class, and able-­ bodiedness matters, but their presence and influence are often subtle,

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muted, or implied. They appear most often in the records as a foil, or “other,” to the presumption of so-called successful development and desirability achievable by white, middle-class, able-bodied subjects. Given that the records reflect the judgment of adult experts, finding and weaving in the perspectives of the children enrolled in the programs is difficult. We therefore endeavour, where possible, to read the records against the grain of adult experts and to be sensitive and attuned to instances when children’s actions suggested active resistance to the often limiting discourse of normative gender identities.6 Finally, we use the term “queer” rather than “transgender,” “lesbian,” “bisexual,” or “gay” in our analysis to cover a range of departures from the normalized ideal.7

The Context of Alexandra Neighbourhood House Alexandra Neighbourhood House emerged out of the Alexandra Orphanage, which opened its doors in 1894 in Vancouver, British Columbia. The orphanage, like many institutions at the turn of the century, was the product of philanthropic concern on the part of middle-class social reformers for those in their midst whom they ­ deemed less fortunate. Members of the local Vancouver chapter of the Women’s Christian Temperance Union secured a house, the precursor to the official orphanage, for the care of three “motherless children.” The numbers of those seeking support and refuge soon grew, and in 1894, the Alexandra Hospital for Women and Children was refurbished to become the orphanage. The building was located in the woods outside the city, and the hospital board of directors thought that the expansive, natural setting was better suited than an urban one to the needs of poor children and also provided privacy and discretion. The building became known as the Alexandra Non-Sectarian Orphanage and Children’s Home of Vancouver, later simply referred to as the Alexandra Orphanage.8 By the early decades of the twentieth century, the orphanage was feeling the burden of declining support from private donations, a trend compounded decades later by the economic pressures associated with the Depression and the growth of welfare services funded by government. To help manage costs and to tap into state services, the orphanage and the popular summer camp it ran elected to join the Vancouver Welfare Federation, a predecessor of the United Way, in the early 1930s.

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Faced with competition from other social services, Alexandra Orphanage had dwindling numbers of children in its care by the 1930s. Between 1894 and 1931, the number hovered around seventy. By 1933, only thirty-seven children remained. By the end of the 1930s, the orphanage became a home for emotionally disturbed children and, at the behest of the School of Social Work at the University of British Columbia, was used as a temporary receiving home by the Children’s Aid (November 1933 to April 1938). In 1938, subsidized foster homes housed the remaining children and the development of a community centre took shape. That community centre, named the Alexandra Neighbourhood House, opened its doors on 1 October 1938. The shift from orphanage to Vancouver’s first neighbourhood house reflected a conscious decision on the part of the Alexandra board of directors. They took advice on the matter after a visit from the first graduates of the first Canadian school of social work at the University of Toronto. The young female graduates recommended that shifting to a neighbourhood house orientation would maximize the social work potential of the organization and better serve the needs of communities.9 Neighbourhood houses like Alexandra grew out of the settlement movement that began in the 1880s in the United States and Europe, peaking around the 1920s. Modelled after Toynbee Hall, an Anglican charity established in London’s East End in 1884, settlement houses expanded into other British cities but found fullest expression in North America, where rising numbers of non-Anglo-Celtic migrants concerned middle-class elites.10 Across the United States, 400 settlement houses were in operation by 1913.11 In the Canadian context, the ­movement thrived in Toronto especially, but Montreal, Vancouver, and Winnipeg were also centres of support for the settlement house movement.12 The most famous American example, Chicago’s Hull House, co-founded in 1889 by Jane Addams and Ellen Gates Starr, typically provided a home away from home for disadvantaged youngsters and their families.13 Many girls and boys found their first introduction to stimulating worlds beyond their families in such settings. Settlement houses everywhere emphasized community regeneration. Poverty was considered to result from the unequal distribution of wealth and inadequate social support, not from innate depravity, incompetence, or indifference, explanations often favoured by conservative ­social critics. The early-twentieth-century Social Gospel inspired many settlement activists to apply a practical Christianity to social ills.14 Yet for  all its sympathetic orientation to urban diversity, the settlement

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movement ultimately promoted white, middle-class standards of health, education, and family life.15 By the late 1930s, many individual settlement houses had evolved into neighbourhood houses such as Alexandra. Such neighbourhood-based facilities, offering an unprecedented range of public services, were hailed as grassroots expressions of invigorated post-war democracy and leisure rights.16 The primary concentration on helping immigrants to adjust to new surroundings was augmented with a focus on the needs of nearby citizens for education, leisure, and more therapeutic social support.17 By the early months of 1939 the in-house A N H newsletter, The Neighbour, which ran from January 1939 to April 1941, boasted that some 124 activities were then on offer, divided among four broad age groups: junior boys and girls, intermediate boys and girls, participants of mixed age, and adults. The activities included gym classes, piano lessons, cooking clubs, boxing lessons, tap dancing lessons, drama, first aid classes, and mending bees (“for mothers!”).18 In a public talk offered in the spring of 1939 at A N H , Lily Peck, secretary of the National Federation of Settlements in New York, praised the progress of A N H and suggested that “numbers of experienced social workers should be secured to assist [first director of A N H ] Mr. [William] Morrison.” She also advised that, “social service students of U.B.C. should take their practical training at the House.”19 With the opening of the University of British Columbia’s dedicated School of Social Work in 1944, A H N did indeed become a placement centre for students and a site for social service work.20 The professional training of social workers, like other aspects of post-war society, was enveloped in the gendered context of the post-war period. While Canadians were told in the popular press and by experts, including social workers, that the end of the war had ushered in a new democratic attitude t­ oward (heterosexual) marriage and family, for example, relations between women and men were still very much subject to traditional thinking about proper gender roles.21 In post-war public schools, sex education was taken up only very tentatively within the existing curriculum and often fell under the title of “family life” education. Information about sex and sexuality remained firmly on the periphery of school curricula in Canada well past the Second World War period.22 As was the case earlier in the century, formal “facts of life” discussions tended to be undertaken outside of schools, in special topic lectures given by medical doctors, or in one or two sessions in health or physical education classes

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in schools. Students rarely heard these lectures in mixed company. When schools did offer sex education, it was often ineffectual.23 For their part, child psychologists linked traditional gender roles and normality in their advice about what it meant to be a good mother and a good father.24 In “How Parents Hinder Adolescents’ Adjustments to the Opposite Sex” leading Canadian educational psychologist Samuel Laycock warned that bad parenting caused homosexuality. A bad parent, among various other things, acted outside accepted gender roles and upset the traditional power balances: “The first pattern of masculinity for either a boy or a girl is the father. Likewise the first pattern of femininity is the mother. Deep-seated ideas and attitudes as to the role of men and women are laid down in the child’s early life. If the mother is the dominating partner in the home and the father is merely a paycheck or a meek and willing servant, that is the pattern which a child has deeply engrained in him.”25 Maintaining traditional gender roles, girls learning to emulate their mothers and boys their fathers, was important if serious personality disorders were to be prevented, psychologists warned. It was in this gendered context, and characterized by newly forged ties between social work and A H N , that programming in support of young people was developed after the war.

P o l i c i n g H e t e r o n o r m at i v i t y a n d P at h o l o g i z i n g Q u e e r at Alexandra Neighbourhood House Social work experts took a particular interest in promoting “normative” expressions of gender and sexuality and closely scrutinized interactions between young participants in programs offered at AH N . These normative expressions tended to be closely linked not only with traditional gender roles and definitions of health generally, but also with young people’s ability to “get along,” to be accepted, to participate fully in activities, and to be well liked. Unfavourable social consequences to nonconformance were framed in the reports as a health problem for the child that was “solved” if the child adopted behaviour in line with the status quo. Children’s behaviour was measured against very specific standards; those who fit were assessed favourably, whereas those who did not were monitored and goals were set for their “progress.” Those who failed to progress were referred for Special Services, which meant they received

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home visits from social workers and eventually psychiatric consultations. Social work students from the University of British Columbia often acted as case workers and performed home visits when children were referred for Special Services. The students were answerable to a larger team, including psychiatrists, as discussed below. The mechanisms of normalization for dealing with problematic children were clearly laid out in meetings held by the professionals responsible for Special Services. In 1955, meetings between employees at A N H , those involved with mental hygiene, and psychiatric professionals delineated criteria for intervention. In a “Meeting to Discuss Establishment of Criteria for Selection of Candidates for Special (Gr. Work) Services,”26 the team settled on eleven behavioural criteria for children between the ages of six and twelve:   1 excessive aggressive behaviour   2 relationship to adults (difficulties in)   3 poor relationship with peers  4 overprotectiveness27  5 fear   6 inability to participate   7 excessive need for control   8 lack of sufficient controls   9 lack of acceptance of controls 10 delinquent symptoms 11 masochistic behaviour A subsequent list of criteria outlines eleven points regarding “members gaining something from group contacts but exhibiting symptomatic behavior,” among them, “confused feminine and masculine roles,” “regressive child,” “frustrated child,” “awkward child,” and “neutral and easily affected child.”28 Records also exist of children being recommended for services on the basis of the category “sexual drives.”29 Records of five groups provide examples of the range of monitoring of children enrolled in A N H programs during the 1950s and 1960s. Records from the Have Fun Together (H F T ) and the Soxy Bobbers friendship groups illustrate the type of everyday reporting on participants’ development. Those from the Junior Girls Social Group provide an example of goal setting to monitor one child’s move toward heteronormative gender / sexuality. The Summer Fun Club records include a write-up on a boy who was recommended for Special Services, while

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records from the Nabe Girls Club shed light on the overlap between children’s programs and the home and psychiatric visits undertaken once Special Services were arranged. The H F T group was formed in October 1950 and consisted of eight girls: five 13-year-olds and three 14-year-olds. According to an “Analysis of Group Record” written by Margot Snell, a group worker assigned to the club, membership depended on “acceptance by present members, friendship basis.”30 In her undated report, Snell offered detailed comments on three girls: Jill, the elected president of the group, Lisa, and Jeannie. The promotion of appropriate heterosexual interest in, and relationships with boys is a recurring theme in Snell’s report and was cast as an unremarkable component of healthy socialization and group belonging. While Jill’s ability to relax around boys and engage them in conversation about baseball is cited by Snell as evidence of her healthy adjustment, her tendency toward “self-consciousness” is underscored as problematic. “She is attracted to boys,” Snell observes, “but doubts her own ability to attract them. At times she has shown her insecurity by attempting to draw boys into horse-play and being over-active, at others she wanted to withdraw, for example, by looking after the record player at the party.”31 Here, Snell places a premium on Jill’s ability to appropriately attract the interest of boys as a matter of healthy group belonging. Conversely, Jill’s shortcomings in this regard are interpreted in psychological terms as evidence of possible maladjustment. Although Lisa was judged to be “like Jill, at the stage when she is attracted to boys but still having difficulty attracting them to her,” she was praised for her willingness to make advances to boys on her own. “Provided she can move on to the next stage,” wrote Snell, “this can be considered as a growth in her social adjustment to the opposite sex … Lisa is developing into an attractive girl. She dresses well, dances gracefully, plays the piano, and has made some of her own clothes.” Insinuating that the “next stage” is heterosexual dating, Snell praises Lisa for demonstrating appropriate gender behaviour and sexual interest in boys. Along with praise, however, Snell offered a caution that underscored the necessity for appropriate limits to heterosexual interaction on the part of well-adjusted girls: “When Lisa is helped to build up her own selfrespect, she will probably be able to relax a little more in her relationships. At the moment, especially with boys, worker suspects that she goes at it too hard – she talks about ‘flirting’ with several.” Jeannie, on the other hand, was praised for taking an active part in all group activities, especially parties, “since these give her an opportunity

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to meet the opposite sex.” Here, Snell again makes a clear link between appropriate heterosexual interest and healthy group membership. While Lisa’s attention to boys was seen as problematic in its intensity, Jeannie’s behaviour was seen as more appropriate. According to Snell, “Jeannie has been using the group as support in her relationships with boys: parties give her a good excuse to invite the one who happens to be at the top of her list at the moment. She switches rapidly from one to another – even the other girls profess to be unable to keep up with her ‘amours.’”32 Snell’s observations suggest that the cultivation of healthy heterosexual relationships in the case of girls meant striking a rather delicate balance. The ability to use group activities such as dancing to interact with boys was cast as a good use of time and energy. Expending too much energy on boys, however, was a sign of possible maladjustment. Welladjusted, normal girls kept intense interest at bay in favour of a breezy, non-committal but nonetheless obvious interest in attracting the attention of boys. Another friendship group running concurrently with H F T , the Soxy Bobbers, had up to seventeen girls between the ages of eleven and fourteen at its meetings in 1950–51. Eileen Stoneby, the A N H group worker, provided several reports on the activities of the group as a whole but did not offer any analysis of individual members. A common activity of the group was to host dances where boys were invited, and Stoneby’s reports were preoccupied with the interaction between boys and girls. She discussed dancing with members of the opposite sex, in particular, as a critically important activity for the youngsters: “Worker didn’t like to see the girls sitting down [and] not dancing … A volunteer danced with Doug and then with another boy trying to help them [the girls] a little.”33 While dancing was undoubtedly enjoyable to some of the girls, not dancing was positioned as a problem to be solved. That the adults actively encouraged the girls to dance illustrates that adult intervention was sometimes required to keep heterosexual courtship on track. In the eyes of adults, dancing in this manner helped secure group membership and reflected positive development. In the mid-1960s, the records of the Junior Girls Social Group exemplify the extent to which “healthy” heterosexual development was constructed against the perceived risk of developing into something else. Initial overviews of the children set specific goals to facilitate their development along normatively gendered lines. As part of a general profile on one participant, Kathy, workers briefly mentioned an incident

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deemed noteworthy. They described Kathy as seeming “friendly but somewhat unsure of what role she is playing (i.e. masculine or feminine) – manifested when she put on a hat and performed in a quasi masculine-feminine role.” This moment of play is noted solely in the context of setting goals for the children in the group. One of the goals for Kathy was “to enable [her] to perceive herself as a girl, with a female body and with the appropriate feminine responses.” The need to encourage demonstrations of “appropriate” femininity was consistent with post-war preoccupations with the “threat” of the homosexual as a societal menace to be avoided. As this example suggests, the monitoring of gendered behaviour began early and can be read in the context of a broader social climate hostile toward homosexuality. Demonstrating appropriate femininity was a precarious act. Disciplinary heterosexuality is reflected in the expectation that the girls enact a narrow balance of enough, but not too much, gendered behaviour. Reporting on Kathy and her peer Terri at the end of term, A N H workers assessed the two children according to their degree of success with the program goals. “Terri is becoming quite seductive – this could certainly develop problems for the future,”34 but Kathy has “learned to become obviously more feminine. She was beautifully dressed for the supper and acted in a very becoming lady-like manner.”35 The ability of a girl to strike this fragile feminine balance was part of being socialized for group membership. Kathy, in the end, was not referred to Special Services. She had met the gendered goals set for her and her sexual / social development was considered to be on a healthy (heterosexual) course. The anxiety of workers about appropriate enactment of heterosexuality is repeated in documents regarding the Summer Fun Club (also known as the Alex Gang). The records of this group for younger children were written ten years earlier, in the summer of 1956. At that time the group consisted of nine boys aged six to eight. One boy, Duane, who failed to meet gender norms, was singled out and recommended for Special Services, and the promotion of normative heterosexuality is explicitly discussed as a necessary intervention. While the threat of homosexuality remains unspoken in the social worker’s report, it is nonetheless implied: “His age [six] did not make for readiness for group membership. He is a slight, shy and delicate child with little ability to cope with the stronger, more active boys in the group. He didn’t make friends or return to the group for the last week. An outstanding need is for Duane to acquire greater masculine identifi­ cation. He lives with his grandparents and his grandmother prefers

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girls to boys. Duane relates more to girls than to boys and has feminine interests and attitudes.”36 The dynamics of Duane’s family, particularly those deemed psychologically unhealthy, figure prominently in his case. His grandmother was judged to prefer girls, thus implying that Duane was not being given appropriate training in masculinity. Indeed, the record explicitly notes his preference for playing with girls. While this preference would be interpreted as normal in older boys, it is understood as highly problematic for a younger boy. Duane’s inability to reject girls and femininity is pathologized. Though he allegedly played with girls who were part of the group, he is recorded as not being ready for group membership. As we have alluded to earlier, positive social belonging is only deemed possible when gendered norms are adhered to. A young boy who plays with girls may have social connections he experiences positively. However, group belonging is equated with the ability to bond in the appropriately gendered way (young boys with young boys). Failing that, he was subsequently recommended for Special Services. In 1957 and 1958, yet another friendship group, the Nabe Girls Club, designed to attract children from nine to twelve years old, operated at A N H . One participant, Janine, was given much attention in the records. Numerous notes elaborate on how her behaviour did not live up to positive group membership, a failure closely tied to her gender nonconformity. The report ranks the status of each participant, and Janine is described as being “the lowest status member in the group,” a position attributed to her “loud, boisterous” behaviour.37 Initial reports on Janine note her low participation in group activities “due to her low frustration level and short interest span. When she loses interest she will invariably run out of the room and disrupt the activities of another group or else start an activity of her own if the room is empty, such as playing floor hockey in the gym.”38 The report goes on to state that Janine “participates best in athletic and masculine activities such as swimming, ice skating, floor-hockey and woodwork. She participates very poorly in feminine or detailed activities such as cooking, sewing or handicrafts.”39 Janine’s refusal or inability to participate in the group in ways expected of her is interpreted as evidence of serious maladjustment. The premium placed on group belonging echoed in the reports on children in other A N H groups was threatened in large part by children who transgressed traditional gender roles. The descriptions of Janine contrast with those of another girl, Brenda, who is discussed as enjoying “the highest status in the group.” The reports focus on her looks as a way of determining good (heterosexual)

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character: “She is a very pretty girl with a medium, clear complexion, rosy cheeks, slight figure, and long, naturally curly brunette hair, usually worn in a ponytail. She is the best-dressed girl in the group and always immaculately clean. Because of these factors almost everyone would be immediately attracted to her.”40 Here attractiveness is equated with enacting normative femininity. It is worthy to note that her desirability ­involves clothing and cleanliness that could require middle-class access to resources. Brenda is praised for participating in all, but especially feminine, activities. This is attributed to parenting: “Brenda’s identification with her mother [is] strong and perhaps this is the reason why she is so fond of feminine activities.” She is praised for participating in activities even when she is not the best at them. When she was at a pool and could not dive while most of the girls could, she “did not run away from the situation like Janine, who played alone for awhile at the shallow end of the pool.” It is not activities alone that were monitored, but how the children participated in them that interested social workers. While Brenda’s lack of skill in the pool was praised as in keeping with demure feminine behaviour, Janine’s ability to swim, perhaps understood as problematic in light of her zeal for “masculine” activities such as woodworking and ice hockey, was pathologized as gender non-conforming. When she doesn’t swim immediately, this, too, is noted as part of her failure to participate appropriately with the group. The equation of successful development with heteronormativity, or accomplishing what is equated with heterosexuality, is reflected in a section of the Nabe Girls Club report entitled “Evidences of Growth.” Here, the cultivation of behaviour that ensured a rigidly gendered heterosexual adulthood clearly emerged as a central goal of the program. The worker discusses having used Janine’s attachment to the leader to help her find more successful ways to be part of a peer group: “The worker also believes that by using the relationship between J and herself, she has helped J identify with a female leader, and perhaps through this identification she has learned to adopt more feminine ways of dressing, talking, behaving, etc. Until J joined this group she had never worn a dress or skirt to the House although she had been attending for many years. This year however, she wore a skirt and blouse on three occasions. The worker also noticed that J was quite interested in the last program which involved cooking, a feminine activity.”41 In the context of concerns about her gender identity, Janine’s iden­ tification with an adult female deemed appropriately gendered is cast in  the report as a good technique for modelling femininity. To be

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successfully gendered, this passage suggests, Janine needed to adopt a set of behaviours and dispositions that “tamed” her boisterous body and behaviour. Janine’s compliance, however, could also be interpreted as an attempt to please the worker as a way to deflect attention, or out of affection (in the way of a childhood crush) for the female leader. The dominant narrative positioned positive (heterosexual) development in girls with appearing conventionally feminine, and this is evidenced throughout the documents not as an incidental reiteration of convention but in the form of explicit program goals. Stereotypical feminine activities such as cooking were marked as positive signs of maturity, whereas increased skills in areas associated with the masculine, such as sports, were positioned as regressive, even dangerous, and invited social exclusion rather than maturation. As is consistent with the era, at no point in the records were children encouraged to widen the margins for group membership to include those who did not conform to dominant norms. Over the course of the Nabe Girls Club notes, Janine underwent several visits from a psychiatrist, including home visits. Reports on the visits focus particularly on qualities, characteristics, and interests that marked her as possibly homosexual. The psychiatrist identified five problem areas, including a “desire to be a boy and subsequent rejection of the feminine role” and “her great need to dominate and feel powerful.”42 Her family dynamics were explored in detail to find why she might, as the experts understood it, have wanted to be a boy. “Her inability to express liking or affection and her tendency to express dislike and hostility were discussed by the psychiatrists,” they wrote, speculating that this might have been due to “pent up feelings of hostility toward her brother which she can’t express, due to his heart condition, and these feelings come out  toward the group leaders.”43 While Janine may have experienced ­legitimate distress over familial circumstances, this was conflated with pathological gender identity and expression. Her preference for ­masculine-assigned activity and her loud, “unfeminine” demeanour were positioned not only as a problem to be solved but as a result of issues at home influencing “unhealthy” non-heteronormative development.

Conclusions We have argued in this chapter that a dual discursive strategy emerged from reports on children at the A N H and provided a framework for our exploration of how social work experts enforced heteronormativity in practice: the promotion (and normalization) of heterosexuality and

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gender normativity, and the pathologization of their absence. These twinned strategies were often deployed simultaneously in the restricted reports, each reinforcing the other. Neighbourhood house staff, social workers, and psychiatrists closely surveyed individual children, as well as interactions between girls and boys, and routinely noted ­gender-inappropriate behaviours. Moreover, adult experts actively promoted activities and attitudes that brought boys and girls into closer contact and modelled heteronormativity. If heterosexuality was normal and good, queer identities were always to be feared and guarded against, and this process of othering occurred implicitly and explicitly in professional discourse. This suggests, at least to some extent, that heterosexuality was a defensive discourse in these decades. The normalization of rigidly gendered heterosexuality as the only healthy option for well-adjusted and popular children meant that all other sexuality identities came up wanting. “Abnormal” sexual identities, moreover, were thoroughly psychologized and pathologized in the expert reports. Even in programs that did not have an explicit thera­ peutic component, such as the Have Fun Together group or the Soxy Bobbers group, individual behaviours and / or group dynamics that could be construed as threatening to the “healthy and normal” development of a heterosexual identity were interpreted as a sign of potentially serious pathology. In cases judged particularly serious, such as those referred for Special Services, interventions into families were a part of a larger culture of heteronormativity. Youngsters enrolled in programming at A N H in the post-war era were educated to understand heterosexual behaviour as the only acceptable path to normality and group belonging. Canadian historians have paid scholarly attention to the place of adults and teenagers in that process, but the role that younger children played has been left largely unexplored. While considerable work remains to be done, our investigation suggests that much professional energy and expertise was in fact marshalled to ensure the successful uptake of these attitudes and behaviours in childhood.

notes  1 Gleason, Normalizing the Ideal; Chenier, Strangers in Our Midst.  2 Adams, The Trouble with Normal.   3  Tamara Myers’ work is an important exception for the earlier period. In “Embodying Delinquency: Boys’ Bodies, Sexuality, and Juvenile Justice History in Early Twentieth-Century Quebec,” she explores the

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criminalization of boys’ sexuality, often overshadowed by the experience of girls, in early twentieth-century Montreal.  4 Adams, The Trouble with Normal; Gleason, Normalizing the Ideal; Gleason, “Growing up to be ‘Normal’”; Gleason, “Disciplining Children, Disciplining Parents.”  5 Chenier, Strangers in Our Midst. On this history of sexuality in Canada, see Chamberlain, “Remembering Lesbian Bars, Montreal 1955–1975”; Ross, The House that Jill Built; Maynard, “Through a Hole in the Lavatory Wall; Barman, “Taming Aboriginal Sexuality: Gender, Power and Race in British Columbia, 1850–1900”; Sethna, “‘We Want Facts, Not Morals!’ Unwanted Pregnancy, the Toronto Women’s Caucus, and Sex Education”; Duder, Awfully Devoted Women: Lesbian Lives in Canada, 1900–1965.   6  Gender conformity was the goal for younger children, while teenagers were expected to add heterosexual dating to the mix. This essay examines both as constituent aspects of heteronormativity. Both contributed to the basis from which children were assessed as having successfully matured, or failed to mature, and both served as criteria for acceptable group membership within the programming at A N H . The analysis also attempts to avoid conflating gender identity and sexual orientation.   7  We also do this to position our work within the tradition of queer theory. Queer theorists have provided critical challenges to the “normal” heterosexual / homosexual “other” binary. As Steven Angelides argues in “Historicizing Bi(Sexuality),” “one of the principal aims of queer theory has been to challenge heteronormative constructions of sexuality and to work the hetero / homosexual structure to the point of critical collapse.”   8  Purvey, “Alexandra Orphanage and Families in Crisis, 1892 to 1938”; Association of Neighbourhood Houses B C , “History,” http://www.anhbc. org/history.php (accessed 20 April 2014).   9  Association of Neighbourhood Houses of Greater Vancouver, Neighbour Houses: Past and Present (n.d), 4, http://www.anhbc.org/history.php ­(accessed 11 April 2011). 10  Mona Gleason and Veronica Strong-Boag, “Community.” 11 Mintz, Huck’s Raft – A History of American Childhood, 205. 12  James, “Reforming Reform: Toronto’s Settlement House Movement, 1900–1920.” 13 Johnson, The Many Faces of Hull-House: The Photographs of Wallace Kirkland. 14 McKillop, A Disciplined Intelligence: Critical Inquiry and Canadian Thought in the Victorian Era. 15  Husock, “Bringing Back the Settlement House,” Public Welfare 51, no. 4 (Fall 1993): 16–26; Cavallo, Muscles and Morals: Organized Playgrounds and Urban Reform, 1880–1920.

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16  Tillotson, “Time, Swimming Pools, and Citizenship: The Emergence of Leisure Rights in Mid-Twentieth Century Canada.” 17  Barbara Trainin Blank, “Settlement Houses: Old Idea in New Form Builds Community,” The New Social Worker 5, 3 (Summer 1998), http://www. socialworker.com/settleme.htm (accessed 29 June 2011). 18  “What Now? New Clubs,” The Neighbour (9 January 1939), 1. 19  “Neighbourhood House Has Distinguished Guest,” The Neighbour (10 April 1939), 3. 20  Before the opening of the School of Social Work, instruction in social work at the University of British Columbia consisted of a two-year diploma course within the Department of Economics, Sociology and Political Science. http://socialwork.ubc.ca/about-us.html (accessed 11 April 2010) 21  On the nature and limits of the democratic model of postwar marriage, see Götz, “Family Matters: The Canadian Family and the State in the P ­ ostwar ­Period; Strong-Boag, “Home Dreams: Women and the Suburban Experiment in Canada, 1945–1960.” On social workers contributions to ideas of normal gender roles in the post-war period see Gleason, Normalizing the Ideal. 22  Sethna, “Animal Sex.” For regional examples of this lack of development, see Arcus, “Characteristics of Family Life Education in British Columbia”; Milham, “Lessons Never Learned.” 23  On the silence and misinformation surrounding sexuality in memories of growing up, see Gleason, “Embodied Negotiations.” For similar histories in the British context, see Davis, “Oh, No, Nothing, We Didn’t Learn Anything.” On Australia see May, “Secrets and Lies.” On the politics of ­silencing sex education, see Irvine, Talk about Sex. 24  Ibid. See also Gleason, “Disciplining Children, Disciplining Parents.” 25  Samuel Laycock, “How Parents Hinder Adolescents’ Adjustment to the Opposite Sex,” Understanding the Child, 14, no. 2 (April 1945): 38. See also Laycock, “Homosexuality: A Mental Hygiene Problem.” 26  City of Vancouver Archives [hereafter C V A ], Alexandra Neighbourhood House [hereafter A N H ] restricted files, “Meeting to Discuss Establishment of Criteria for Selection of Candidates for Special (Gr. Work) Services,” M S S 420, M-103, reels 12–15, 1. 27  Although no explanation is offered for children’s “overprotectiveness,” it may have referred to a problematic tendency to worry over, or suffer anxiety about, the well-being and affections of friends. It might also have referred to a problematic level of attempts to curry favour on the part of a child. 28  C V A , A N H restricted files, “Meeting to Discuss Establishment of Criteria for Selection of Candidates for Special (Gr. Work) Services,” M S S 420, M-103, reels 12–15, 2. 29  Ibid., 4.

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30  C V A , A N H restricted files, “Analysis of Group Record, H F T Club, Alexandra House,” M S S 420, M-103, reels 12–15. All proper names have been changed. 31  Ibid, reel 11. 32  Ibid., 17. 33  C V A , A N H restricted files, “Friendship Group, 12–14, Introduction, Friday Oct. 6th.” 34  C V A , A N H restricted files, “Junior Girl’s Social Group Record, Alexandra House,” M S S 420, M-103, reels 12–15. 35 Ibid. 36  C V A , A N H restricted files, “Individual Reports, Alex Fun Gang, Alexandra House,” M S S 420, M-103, reels 12–15. 37  C V A , A N H restricted files, “Analysis of Individual Members, Nabe Girl’s Club, Alexandra House,” M S S 420, M-103, Reels 12–15. 38 Ibid. 39 Ibid. 40 Ibid. 41 Ibid. 42 Ibid. 43 Ibid.

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10 The Heterosexual Nature of Health and Hygiene Advertisements in the Cold War Era Thomas Wendelboe Since the middle of the twentieth century, the idealized female body has been shrinking. Marilyn Monroe was a size eight when her idolized ­figure adorned the inaugural issue of Playboy magazine in 1953. Five decades later, men’s magazine Maxim awarded Christina Aguilera, a ­petite size two, the top spot in their “Hot 100” list of the most de­sirable women.1 According to scholars, popular culture’s crusade for shrinking waistlines and dwindling dress sizes created an idealized body exploited by marketers to sell products promising thinner, more attractive, and ultimately more sexually desirable bodies. In deconstructing advertisements, psychologists, sociologists, historians, and a host of ­other academics liken the prescriptive authority of advertisements with regard to the ideal body to that of the medical profession with regard to the healthy body. Like medical professionals’ presentation of the idealized medical body, portrayals found in popular culture can produce tangible consequences for women.2 Professor of English and women’s studies Susan Bordo, for example, describes advertisements and other visual media as having a sometimes-fatal power over the health of women’s bodies, arguing that practices such as cosmetic surgery and obsessive dieting are tied to the continued normalization of patriarchal gender ideals promoted through popular culture.3 Other scholars have directly examined the link between advertising and medical authority. In chapter 11 in this volume, Wendy Mitchinson details how phar­maceutical ads for obesity medications drew upon traditional notions of masculinity and femininity to create a sense of familiarity with physicians. Sandra

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Coney argues that ads for menopause medications routinely used slogans, such as “Menrium treats the menopausal symptoms that bother him the most,” that reinforced the subservient nature of womanhood.4 Advertisements, then, produced an authoritative gaze that mimicked, and in some instances informed, that of the medical profession and produced an unhealthy discourse that facilitated the subordination of women through the marginalization of their bodies.5 But what of the male body? New scholarship is emerging that examines the consequences of the medical gaze for men, such as Antje Kampf’s discussion of male infertility in chapter 6 of this volume. Others have noted that health conditions such as muscle dysmorphia and the abuse of anabolic steroids as well as cultural signposts such as the proliferation of fitness facilities and the growth of the supplement market indicate that men suffer from an unhealthy obsession with the ideal body similar to that suffered by women. While the rise of bodybuilder culture, for instance, offered a glimpse into obsessive masculine body practices, there has been little examination of popular culture’s authority over the image of the masculine body6 and the consequences of visualizations of health for men and masculinities7 or a deconstruction of the self-regulatory power of masculine imagery in popular culture. What follows is a case study of depictions of the advertised male body found in men’s leisure magazines Playboy (1953–present) and Esquire (1932–present) during the Cold War. These periodicals were designed to appeal specifically to a masculine audience and, as such, provide a rich source base from which to study the consequences of masculine consumerism.8 The idealization of masculinity is not limited to a single epoch or visual medium, but print ads published at the middle of the twentieth century illustrate the ­relationship between consumer capitalism and identity politics. More importantly, the culture of sexual surveillance arising from fears of the  perceived homosexual infiltration of American society provides a compelling backdrop against which to explore the regulatory nature of advertisements. Drawing from the research on the idealization of the female body, this chapter argues that culturally constructed images of the male body displayed similarly unhealthy stereotypes. Studies such as Anika Stafford and Mona Gleason’s examination of Alexandra Neighbourhood House in this volume (see chapter 9) have explored the role of the expert in normalizing heterosexual behaviour while Tracy Penny Light’s chapter details how medical discourse has normalized the body through an

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examination of cosmetic surgery (see chapter 13). In this chapter I examine the normative pressure of popular culture through a study of health and hygiene advertisements. Concepts of health and hygiene are linked to notions of discipline and the body. In chapter 3, Meg Parsons details how Australian officials regulated Aboriginal bodies through the discourse of health and hygiene during the first three decades of the twentieth century. Officials prescribed hygiene practices to shape “suitable, although not necessarily equal, members of society” through the authoritative power granted by medicine. I argue that by mid-century advertisements had become a source of medical authority as marketers increasingly looked to health to legitimize their products. The male body of the Cold War era was predominantly on display and, as this chapter argues, often linked to images of idealized healthy vitality. There were also consequences if one failed to live up to the healthy ideal, and advice literature, advertisements, and, at times, the medical profession warned of the uprising of the effeminate male. As a diseased spectre of masculine failure, this image was most commonly associated with homosexuality and, as discussed later, was seen as inherently unhealthy. Marketers capitalized on consumers’ fear of appearing weak and instilled a sense of authoritative power in their advertising campaigns offering a wide range of products that men could purchase to reaffirm their masculinity, such as colognes, aftershaves, deodorants, styling gels and alcohol. I begin with a consideration of the use of advertisements in general, specifically the way in which many of the advertisements in Playboy and Esquire used the concept of the healthy body to sell products not normally associated with health. Advertisements represented the visualization of health and hygiene and as such had an authoritative quality. I then consider the historical context of the time with respect to masculinity. I argue that both periodicals contributed to and reflected wider societal discourses on masculinity, chief among them the popular perception that homosexuality represented a weak-willed, effeminate failure and the inability to control one’s body and that it was something to be avoided at all costs. Particular attention is paid to the influence of Alfred Kinsey’s groundbreaking work on sexual behaviour. Kinsey had a broad influence on sexual politics and what was seen as the sexual norm and consequently a healthy norm. Influential in the understanding of masculinity was the role of sport and how the image of the male athlete became the persona of hyper-masculinity. In advertisements, the healthy male body was a disciplined body, as ads depicted an ideal focused on

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control and men who were unable to perform in either the bedroom or the sporting arena faced the fear that they could not adequately display the health of their body. Advertisements drew upon these desires, playing to men’s fears and, at the same time, reinforcing them. Finally, I survey the pages of Playboy and Esquire and detail how health was visually depicted as a heterosexual domain through an examination of advertisements and articles appearing in those periodicals, arguing that masculinity was constructed through the visible rejection of undesirable, and what could be considered unhealthy, traits.

Reading the Visual The emerging field of visual culture provides methodological guidelines for the study of advertisements. Images, like any source, require an understanding of the context in which they appear.9 Stuart Hall argues that audiences do not passively receive, or decode, visual sources such as advertisements because producer and consumer do not share identical cultural or contextual backgrounds.10 Instead, some negotiation and opposition occur as consumers imprint their own experiences onto their reading of an image.11 Similarly, French literary theorist Roland Barthes contends that advertisements invoke multiple layers of interpretation. For example, a product’s name not only identifies a brand but also carries a connoted message. Playboy is not only the title of a magazine but also the signifier of a certain lifestyle.12 Barthes’ example highlights the importance of text within advertisements, a discourse that carries “the fundamental contradictions of our culture.”13 It is in the best interest of advertisers to emphasize recognizable and engaging imagery. By appealing to the widest possible audience through contextual signifiers, they ensure that their products will garner a positive reaction. Marketers used health as a means to advertise their products, many of which appear to have little to do with health, by presenting an idealized version of the healthy male body in an effort to form an authoritative connection with the consumer. This visualization connected practices, some of which could be considered unhealthy, with good health and created a dominant discourse that celebrated heterosexual conquest and sporting prowess. Many of these items were hygiene products, such as scents, deodorants, and colognes, presented to men as a means of making their good health visual. Hygiene products, then, are any items that use the senses – sight, sent, touch, hearing, smell, and taste – to link health with the body through the connection with and the perception

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of cleanliness. Although scents may simply mask or falsify desirable or undesirable odours, they are used to create the illusion of health and to project a sense of control over one’s body. Conversely, advertisers also drew upon ideals commonly associated with good health to grant their products a sense of contextual authority. Academics have linked the pursuit of sport to notions of ideal masculine health, arguing that displays of sporting prowess, in sports from tennis to football, celebrate traits commonly associated with good health: physicality, strength, power, and, sometimes, violence. Good health was desirable and these products offered men a means to demonstrate their adherence to social mores through sound grooming and acceptance of sport. Advertisements ranging from deodorants that promised sexual prowess to celebrity-­ endorsed hair creams drew upon the notion that the body reflected one’s masculinity and were presented to consumers as a means of displaying their health publicly, either through the use of hygiene products that visualized health or by drawing on health as an ideal. In both instances, these depictions of health marginalized the feminine Other, limiting the role of women to playmate and casting homosexuality as an effeminate spectre for those unable to measure up to popular culture’s definition of what was healthy. What is important is the notion that marketers subsumed the regulatory power of medical authority. The consequence of this shift remains understudied in the context of men and masculinity.

Masculinity R.W. Connell argues that a hegemonic masculinity maintains society’s patriarchal gender hierarchy but it does not necessarily need to be the most prominent in society. Instead, hegemony operates as the ideal perceived to be most socially accepted.14 At the mid-century mark, maleness meant heterosexuality. In June 1950, the US Senate investigated the presence of homosexuality amongst government workers and argued that an individual found engaging in homosexual activity lacked the moral fortitude required of a government worker and had a “corrosive influence upon his fellow employees.”15 In his examination of Cold War culture in the United States, historian Kyle A. Cuordileone links the government’s treatment of homosexuality to an overarching attitude that viewed homosexuals as “maladjusted individuals” who associated with communists and other miscreants. A growing social and legal discourse grouped these “undesirables” together and cast them as

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a weak-willed and effeminate foil to American masculinity.16 The hegemonic body of Cold War era man was “economically successful, racially superior, and visibly heterosexual.”17 Not only was heterosexuality ­considered socially and politically healthy, it was considered to be mentally so. After all, homosexuality was listed in the D S M (Diagnostic and Statistical Manual of Mental Disorders). Despite the existence of what appeared to be a hegemonic male body, challenges to it were made. Central was the work of Alfred Kinsey. Statistics in Kinsey’s pivotal 1948 book, Sexual Behavior in the Human Male, revealed that homosexual behaviour – and indeed male sexual activity generally – was more prevalent than previously thought. The study found that 37 per cent of adult men confessed to engaging in homosexual behaviour and 85 per cent of American men engaged in intercourse out of wedlock.18 Kinsey himself advocated acceptance of “non-normative” behaviour and influenced some leading journalists to do so as well. Nevertheless, many mainstream outlets used his work to magnify the “danger” posed by sexual “deviants.”19 McCarthyism linked the effeminate homosexual with communism, while a “communist-­ homosexual conspiracy” was envisioned in some circles and defined as a dangerous threat to American society.20 As noted above, the government spent vast sums on investigating possible homosexuals, and police infiltrated and disrupted gay meeting places and organizations.21 By the 1970s, “debates raged and battles were fought” over homosexuality in “virtually every area of American life.”22 The rise of gay liberation movements during the 1960s and 1970s to combat society’s homophobic nature was a response to the continued culture of sexual intolerance in the United States.23 At the same time, works such as Peter and Barbara Wyden’s Growing Up Straight: What Every Thoughtful Parent Should Know about Homosexuality (1968) and Lawrence Hatterer’s Changing Homosexuality in the Male: Treatment for Men Troubled by Homosexuality (1970) reinforced homophobic beliefs and supported a culture of sexual oppression.24 Popular culture surveyed and controlled the male body through cultural signifiers such as Playboy and Esquire in which marketers used the discourse of healthy sexuality to grant authoritative power to their ­advertisements. By using heterosexual undertones, marketers played to male insecurities and, perhaps somewhat inadvertently, served as a form of societal regulator for the male body. Despite appearing sympathetic to the “homosexual question,” both Playboy and Esquire ultimately ­celebrated heterosexuality. As this chapter argues, the advertisements

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reflected the overarching hyper-heterosexuality of the publications in which they appeared. Men’s leisure magazines celebrated hegemonic masculinity, a practice that “jeopardized” the American man’s self-­ image by creating an unattainable ideal.25 Advertisers also drew from the authoritative power of sport, a disciplinary career both in its own right and as part of a larger discourse on health, through celebrity endorsements and suggestive imagery. As suggested above, men were pressured to prove their heterosexuality. Sport provided a homosocial arena for men to demonstrate their rejection of effeminacy through their dominance over other men. Masculine sporting institutions of the twentieth century offered a test of masculinity that bolstered the ideology of male superiority by celebrating characteristics associated with the hegemonic male ideal.26 Traits such as strength, aggression, power, and violence were as integral to sports as they were to Cold War era manhood, which, according to sociologist Steven Schacht, made sport “femininity’s antithesis.”27 Sport provided a foundation for the construction of the masculine hegemony. Athletics gave men the opportunity to display the idealized healthy body that was symbolic of twentieth-century masculinity. Men unable or unwilling to participate in sporting events found themselves ostracized and labelled with derogatory slang – from “homo” to “pussy.”28 Sport was used in advertising to marginalize homosexuality through the promotion of hyper-masculine heterosexuality.29 Ads employed the rugged imagery of sport to market products that promised the power of sporting masculinity, without the necessity of participating in athletic events. This way, men could adhere to the masculine ideal through their consumerism and consequently demonstrate their rejection of the marginalized, effeminate form of masculinity. The use of sport in advertisements, combined with an increasing editorial focus on sport that, at times, celebrated the rough and violent nature of competition, celebrated the masculinity of successful athletes. The appearance of sporting masculinity within the magazines reinforced the need to dominate femininity in women and effeminacy in men themselves. Athletics offered men an appropriate stage to display the traits commonly associated with masculine dominance. Sport marginalized femininity, reinforced traditional gender roles, and marginalized the effeminate homosexual, embodying a staunch heterosexuality that was picked up in magazine articles and in advertisements that used the hegemonic authority of sport as a selling tool for products both healthy and unhealthy.30 Ads and advice literature depicted the dominant tenets of masculinity and

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emphasized an idealized identity as marketers drew upon the authority associated with health to market their products, effectively allowing consumerism to discipline the male body. According to Playboy and Esquire, the healthy male had to embrace and display the prevailing characteristics of masculine supremacy. When read in the context of the Cold War era, marketers’ allusions gave consumers a sense of familiarity through the marginalization of homosexuality, reflecting a wider cultural abhorrence of a criminal act, and the celebration of the homosocial sporting arena.31 Advertisements promised to enhance one’s masculinity or drew upon the healthy vitality associated with sport to sell both healthy and unhealthy products. Connell indicates that the use of sport to sell items such as liquor created unrealistic expectations of American men. The sociologist conducted interviews to reveal that sports stars often marketed products that they did not use themselves. A sports star who served as the marketing face of a brewing company, for example, admitted that his rigorous training required that he abstain from alcohol as any liquor consumption was detrimental to the health of his body.32 The reliance on sport imagery disciplined the body’s sexuality. Athletes were admired for their strength and strong moral character, traits opposite those of homosexuals, who were stereo­ typically perceived as feeble, effeminate, and weak willed.33 These depictions reflect an intersection of the visualization of health, male insecurity, and popular culture and presented heterosexuality as physically and psychologically healthy. Both Playboy and Esquire brought together numerous facets of masculine consumption and attempted to “displace all the women-identified associations so firmly lodged at the center of America’s commoditized domestic environment” through cheesecake pin-ups and ribald humour.34 The combination of hyper-heterosexuality and consumerism appealed to Americans. By the 1960s, Playboy alone generated $4 million in revenue, indicating the widespread appeal of the “horny-handed machismo” found within the pages of such magazines.35 As English studies professor Bethan Benwell argues, such arteficts of popular culture “illuminate aspects of the condition of modern masculinity.”36 In Playboy and Esquire, advertisements connected products to consumers by alluding to distinct, but connected, hegemonic identities: the womanizer and the athlete. Hygiene products such as shaving cream and cologne designed to make men heterosexually desirable promised to aid them in their sexual conquests. Similarly, hair products and Scotch were

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sold by tough-as-nails sports stars who served as an authoritative embodiment of masculine health.37

D i s c i p l i n i n g t h e B o dy t h r o u g h t h e V i s ua l In the 1950s, advice literature in Playboy and Esquire prominently featured the work of sexual behaviourists such as Kinsey; however, his work was used to reinforce the heterosexual message of the publications. In 1953, Kinsey supplemented his work on male sexual practices with the publication of Sexual Behavior in the Human Female. Kinsey’s findings generated a great deal of public debate, and many view his work as an early precursor to the sexual revolution. Writing for Playboy in the 1960s, Ernest Havemann remarked that “anyone who writes on sex would be a fool not to consult with [Kinsey’s] Institute for Sex Research.”38 Columnists consulted Kinsey’s work with fervor but often conflated his findings with their own sexual dogma. One article appearing in 1955 used the work of the sexual behaviourist to justify the “playboy lifestyle.” Titled “Don’t Hate Yourself in the Morning: You Weren’t the Only One Having Fun,” the commentary stated that a man who felt remorse for “seducing young females” should find “balm for his scruples” in Dr. Kinsey’s finding that the girl who was “ruined a little bit before marriage made a better adjusted wife.”39 The author, Jules Archer, also cited other sexual behaviourists such as Herbert Lamson and Lotte Fink, arguing that women enjoyed sex and seduction as much as men did. Archer’s crude article both championed a woman’s right to sexual freedom and cloistered her within the confines of traditional gender hierarchies. He allowed for sexual promiscuity but argued that the practice benefited men. By bringing Kinsey’s work to the forefront of society, Playboy cleared the masculine conscience and justified the continued sexual pursuit of “unspoiled” women.40 Archer’s manifesto drew responses from Playboy’s readership that reflected American society’s gender divide. Men sent accolades to Playboy for “having the guts to bring the truth out in the open,” while women were more inclined to label the article a “vile piece of anti-individualist propaganda.”41 One male reader went as far as to proclaim that Playboy was worthy of “some sort of medal good for a free case of beer”; another believed the article to be the “most honest, down to earth chronicle” that he had ever had the “pleasure of reading.” One reader, R.P.A., wrote to let the magazine know that his attempts to put Archer’s pro­ posals into practice had led to “a swollen eye, and two lumps on [his]

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chin.”42 The flurry of letters sent by an alarmed female readership reinforced R.P.A.’s practical experience: the article elicited a furious response from women. K.B. questioned Archer’s sexual experience, noting that “he should try writing again when he gets to about his fifth woman,” while J.R. denounced the author as an unhappy bachelor, unable “to find a mate of the opposite sex to live with.”43 Faced with such scorn, Playboy’s editorial team was unwavering, reinforcing Archer’s point that “if a young lady goes to bed with a man it is because she wants to and any weeping and wailing that takes place, before or after, is for his benefit and to ease her conscience.”44 Reader letters indicated that the magazine’s heterosexual message had hit a chord with its male audience while the outright dismissal of women’s concerns reinforced a larger patriarchal discourse. The visualizations of masculine health found in advertisements in both Playboy and Esquire reflected the opinion of Archer and reinforced the commonly held views of the male audience. Marketing schemes for products such as Preferred Stock cologne by C O T Y promised men a “secret weapon” to use in their now-justified sexual conquests.45 The advertisement, appearing in the July 1955 issue of Esquire magazine, featured a picture of a debonair man dressed in a suit, calmly standing over a collection of C O T Y hygiene products while the woman on his arm stared infatuatedly at him. Another ad marketed a self-help book by “practicing Washington, D.C. psychiatrist” Frank S. Caprio that promised to provide men with the information they needed “about women, the importance of sex … [and] the art of lovemaking.”46 This example of advice literature, titled The Adequate Male, came complete with a ­money-back guarantee and offered men “practical step-by-step plans of action” for “achieving adequacy as a male and the health and mental well-being that go with it.”47 Taken together, the dominant message appearing from this discourse was one of masculine control. Presumably, the C O T Y products aided the C O T Y man in his personal quest to discipline his body and the submissive women on his arm represented the reward for doing so. More importantly, The Adequate Male connected sexual conquest with masculine competence and sound mental health. What about men such as R.P.A., who were not as successful in their romantic dealings as the masculine identity demanded? A sore lip and bruised ego would hinder any attempt to adhere to the visualized healthy masculinity depicted within the magazines ads. Recognizing that not all men were natural “lady killers,” marketers also deployed ad campaigns that referred to twentieth-century sporting institutions to

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provide other avenues for the conquest required of masculine validation. An advertisement for Sportsman cologne by the John Hudson More Company marketed itself as “the very essence of good grooming” and was based squarely on the image of hunting for sport. The fullpage spread appeared in the December 1955 issue of Esquire magazine and featured a man leading a hound dog through an urban landscape.48 In this instance, marketers used sport to link their product with frontier masculinity. The frontier was commonly associated with a “heroic” masculinity now vanishing, and marketers instilled the notion that their “grooming essentials” had the ability to reconnect men with nature.49 Drawing on notions of frontier masculinity that typically excluded women, advertisers contextualized their products through a sense of nostalgia.50 The ad for Sportsman reflected not only the link between sport and nature traditionally associated with American society but also the nostalgic connotations of sport itself. Authors of this period often pined for the days when sports such as baseball engendered “the community spirit, and the intimacy,” of past America.51 Sport offered a respite for the beleaguered American male and represented a return to a mythologized era when patriarchal control was clearly defined.52 Hunting allowed men to conquer nature, and products introduced by companies such as John Hudson More gave them the opportunity to express their adherence to a particular masculine ideal. Nature was yet another avenue for the expression of visual displays of control. By dominating women, men were demonstrating their maleness. By keying in on a sense of wistfulness associated with the frontier, advertisements further reinforced the notion that the public displays of one’s health represented by good grooming were exhibitions of control. Images of man as womanizer and man as hunter, whether distinct or overlapping, were supplemented by images of man as athlete. Since at least the turn of the twentieth century, the athletic ideal has been associated with good health as the sport celebrity displayed his healthy body by using it to control others in the sporting arena, and marketers drew upon this belief to present their products as desirable. This image drew upon context provided by the magazine’s editorial content. Playboy and Esquire clearly relayed the message that sport was a homosocial construction that reinforced desirable masculine traits. An excellent example of the masculine candour associated with sport appeared in Paul Gallico’s March 1955 monthly column This Man’s World, in Esquire magazine. Gallico detailed the life of one of the “world’s greatest athletes,” Mildred

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Ella “Babe” Didrikson Zaharias, an American who competed in a multitude of sports, including track and field and golf. She remains the only woman to have made the cut in a regular PGA tour event.53 Gallico described Didrikson Zaharias as a “tough, hard-boiled girl” who was of “medium height, made apparently of rawhide, with taffy colored hair, green eyes, and a prominent Adam’s apple.” He claimed that she “wasn’t pretty” and, as a result, had abandoned the feminine sphere for “the field of sport.”54 Gallico implied that Didrikson Zaharias was successful athletically because she had replaced many of her feminine traits with masculine ones. In the author’s view, there was no room for women in the sporting arena, as Didrikson Zaharias was only able to embody the ideal once she rejected her femininity. Didrikson Zaharias was healthy, but not in a gendered way. For the author, a woman could not be a sports star without first giving up the very traits that made her a woman. Sport was a man’s domain and it was a rough, masculine affair. Articles emphasized the rugged, and thus masculine, nature of athletics. Boxing, “one of the very best sporting events to watch,” was the subject of articles in both magazines.55 W.C. Herne wrote that boxing was a brutal sport in which successful men appeared to be born with a vital characteristic – “too much guts.”56 In an interview with an aspiring combatant, Herne asked, “Does it bother you that your face is getting marked?” to which the boxer simply replied, “No.”57 To the boxer, the scars of combat were markers of his masculinity. By drawing on sport, marketers granted their ads a sense of contextual authority and reinforced the heterosexual nature of masculine health. In an effort to legitimize their products, advertisements connected with the commercial exploitation of sexuality in the 1950s, which reinforced society’s patriarchal nature and normalized female subordination. Men were told that women wanted to “have a good time” and that sexual pursuit of them would provide a “service for society.”58 While editorial content such as Archer’s informed men of their sexual responsibilities, advertisements armed them with the weapons they needed to make the opposite sex surrender. Advertisements for a host of hygiene products capitalized on this discourse and connected visualizations of the healthy body with heterosexual prowess. Smelling and looking good were essential to sexual conquest, which in turn was linked to masculine hegemony and ideal health. Likewise, products drew on the health ­ideals associated with sport and reinforced the notion that men’s health was about controlling one’s body and demonstrating a visible rejection of femininity, either through sexual conquest or sport.

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The 1960s witnessed further separation of masculinity and femininity, as the opening salvoes of the 1950s turned into a heterosexual battle cry. The work of Kinsey and others had led to an emerging public discourse that provided identifiable consequences, such as homosexuality, for those who failed to embody the healthy male identity. Editorials claimed a liberal doctrine of sexual tolerance, but advertisements and the occasional article eschewed tolerance in favour of a heterosexually charged masculinity. Products endorsed by prominent sports figures promised men a complicit heterosexual identity. Advertisements in 1960s Playboy and Esquire exploited a growing unease over “the homosexual question” to provide a sense of contextual familiarity and connect the consumer with their product. Ads presented a healthy male identity that manifested itself as insistently heterosexual through either overt displays of courtship or the hyper-masculine arena of sport. Kinsey’s work continued to attract interest from the popular press well into the 1960s, but whereas earlier articles had looked to Kinsey to justify the bachelor lifestyle, those in the new decade did so to tackle the issues of homosexuality. However, his work was open to interpretation. Writing in September 1965, Ernest Havermann juxtaposed Kinsey’s work with his own personal experiences. While acknowledging Kinsey’s statistical examination of homosexual behaviour and the notion “one man in three has at one time or another had a homosexual experience reaching the point of orgasm,” Havermann quickly reminded his readership that “the experience does not necessarily make a man ‘queer’ at all.”59 To bolster his point he recalled a story of a classmate who was caught engaging “in some sort of nameless shenanigans one night” with another male. Havermann detailed how word of the indiscretion got around and resulted in mothers refusing to “let their daughters have anything to do with him,” which made the “poor fellow” the “unhap­ piest man alive … until at last he moved away to another town, got ­blissfully married and sired six healthy children.”60 Editorial content excused “queer” transgressions but avoided condoning homosexuality as a life choice. Ads offered a separate interpretation of acceptable ­sexual practices. Marketing campaigns for a variety of hygiene products aggressively employed masculine–feminine relations as the ground where men could assert their patriarchal dominance. Ad campaigns in both Playboy and Esquire featured colognes and aftershaves that they promised would “separate the men from the boys … but not the girls.”61 The Max Factor company ran advertisements in both magazines that highlighted its

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products’ ability to sway the opposite sex. Above a selection of merchandise that included the Busy Man’s Bar – a trio of aftershave, hair dressing, and cologne – a debonair male smirked through a keyhole with an adoring woman at his side.62 Similarly, Blackwatch cologne advertised itself with the slogan “Watch what it does for a man!” In these advertisements men always appeared to be in control and women at their mercy, their longing looks symbolizing the power that the correct scent could have. Advertisers of hygiene products constructed a hyper-masculine identity and then positioned good grooming at its centre, overtly emphasizing heterosexual conquest. Since good hygiene signified good health, the healthy man had to be in control of not only his own body but women’s bodies as well. Throughout this period, visualizations of health continued to normalize hyper-heterosexual behaviour through advertisements that depicted men as confident playboys and women as submissive playthings. An ad that appeared in both magazines, for By George cologne by George Caryl Richards, Inc., included the words “The most persuasive fragrance … is his” above the image of a woman who appeared enthralled by the product.63 Another cologne, Kent of London, was advertised as something that “women have never been exposed to,” a factor that the marketers insinuated would make someone sexually irresistible to women.64 Hygiene products carried a distinct message of heterosexuality. Appearing in both Playboy and Esquire, Revlon’s marketing campaign for its men’s cologne That Man reinforced the dichotomous relationship of masculinity and femininity. That Man was advertised as a “man’s man’s fragrance.” Other advertisements, as well as the tepid response to homosexuality and celebration of heterosexual conquest in the editorial pages, clearly indicated that a “man’s man” was in fact a ladies’ man.65 Black Label, a collection of toiletry products for men, simply stated, “Some guys have it. Some guys never will.”66 “It” was the heterosexual vitality represented by the content of the periodicals. Advertisements hinted at the consequences of masculine failure while presenting their product as a solution to perceived deficiencies. By the mid-1960s, the correct aftershave gave “any man the license to kill … women,” while other scents would hover “close to the skin for hours [and] transmit a virile message.”67 By marketing products through promises of increased sexual prowess, the advertisements responded to the perceived threat of homosexuality by taking a more aggressive tone over the subordinate other. Like heterosexual virility, success in sport remained a viable means for advertisers to contextualize the importance of their products to the

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consumer. The practice of sport branding continued as typically unhealthy products such as alcohol made direct reference to athletic feats and a variety of hygiene products employed sports symbolism.68 Trends that had emerged in the 1950s continued despite some editorial backlash, and by 1965, hyper-masculinity and sport were becoming visibly linked within the discourse generated by the marketing of hygiene products and the use of healthy ideals in advertisements. While editorial content, most notably cartoons, satirized the flood of product endorsements, sport was very much an acceptable masculine domain by the 1960s. A cartoon in Esquire featured a burly man working a quarry with three men in suits posing the question to the lone worker: “Hi, there, big fellah! How would you like to try a man’s cigarette?”69 Playboy featured a cartoon depicting an announcer standing over a defeated boxer with the tag line “Just a reminder, folks … Spider Smith does not use Gillette Blades.”70 However, the satirical content was countered through articles that expressed admiration for sport and advertisements dependent on the endorsement of sports stars. For instance, an article by Charles O. Puffer appearing in the October 1960 Playboy issue reinforced the link between sport and frontier masculinity. Puffer wrote about “attractive tracts of land near major urban centers” that were being converted into hunting preserves.71 He noted that these facilities presented the “urban gentleman” with weekend access to hunting. Puffer’s sentiments were echoed by a plethora of advertisements that linked sport with consumerism. Advertisements spoke to the believed urban desire for the combination of sport, outdoor life, and nature, creating contextual familiarity through product branding. Sport, and the ideals of health it was commonly associated with, became a key component of marketing strategies in the 1960s as advertisers looked for ways to grant their products power in the marketplace. Advertisements now routinely featured products endorsed by nationally recognized sports figures and provided men with a way to emulate a version of masculinity through consumerism. The Dandricide company, for example, marketed its product in Playboy magazine as the solution for the “sportsman” with dandruff: “Jim O’Day knows his outboard must be kept after if he expects it to run under all conditions. ‘Conking out’ at the wrong time may be dangerous. Jim is as meticulous about his motor as he is about his personal grooming. In business or pleasure, he knows dandruff may hinder his chances of success. Can’t say D A N D R I C i D E has increased his personality and charm … B U T the assurance most men gain from rinsing their hair with D A N D R I C I D E has played an important part.”72

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This ad linked grooming with the images of the sportsman, drawing comparisons between the body and success. Teacher’s Scotch continued a sport-based ad campaign from the 1950s, linking golf and skiing with liquor and including images of sports celebrities with their ads. Now advertisements featured photographs of such notable sports stars as “Gene Sarazen, U.S. Open, British Open, P.G.A. and Masters Champion.”73 Teacher’s also sponsored a trophy for the PGA Senior’s championship winner. In a nearly full-page advertisement, “A.L. Home Run Slugger” Harmon Killbrew endorsed the Northcool Vyctott suit, made out of “Slugger Selects Vycron polyester fiber,” exclaiming that the polyester he endorsed was “in a league by itself.” 74 Controlling the public appearance of one’s body not only signified good health, it also relayed a sense of masculine control and an adherence to the masculine hegemony. The discourse generated by the marketing of hygiene products and by ads’ use of sports imagery reinforced the patriarchal nature of society and the subversion of homosexuality. By 1965, magazine articles routinely discussed the masculine aspects of sport while advertisements explicitly celebrated the values of sporting masculinity as a means of controlling and managing one’s body and masculinity. An Esquire article detailed the virtues of sports figures such as “the world’s most famous practicing mountain climber,” Walter Bonatti.75 Bonatti and other “solitary heroes” were admired for their ability to manage risk while engaging in dangerous activities such as bull fighting and race car driving.76 Another article detailed the importance of high school football in Ohio, stating that the “Kids sacrifice year round: ‘one hundred percent all the time, so that way there’s no possible way of getting beat.’”77 Advertisements tied sporting success to success with women. Sportsman cologne was advertised as a means to “light a new fire under an old flame,” while Match Play marketed itself as a “great new cologne, definitely male, with a clean sporting scent that lasts and lasts.”78 Both ads featured women in submissive roles, and the one for Match Play showed a woman adoringly sniffing at her male counterpart. The 1960s witnessed a merging of factors that referenced the consequences of sexual failure: sissification, effeminacy, and homosexuality.79 The commercialization of sport further emphasized the central role athleticism played in demonstrating one’s masculinity, and the association of heterosexuality with sport, often through hygiene advertisements, brought two exclusionary identities together, visualizing health’s rejection of homosexuality.

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Advertisements for health products in the 1970s reflected a culmination of trends that had begun in the previous decades. The “homosexual question” had gained prominence in the media, prompting numerous editorials and articles, while sports continued to merge with commercial activity. As in the 1960s, visualizations of health depicted a masculine identity that marginalized the homosexual other, as the language of  advertising reflected sexual omission and championed the hyper-­ masculine accomplishments of sport. Playboy attempted to maintain a dialogue on prominent liberal issues through a monthly column entitled Playboy Forum, in which editors collected and commented on stories that they thought pertained to the “playboy lifestyle.” In February 1970, the issue of homosexuality was at the forefront in the column as the editors discussed the question “Are Homosexuals Sick?” It was responding to an article in Time magazine in which a New York psychoanalyst concluded that homosexuality was “a form of emotional illness.”80 Playboy not only weighed in with its own interpretation of homosexuality but also published the views of many of its subscribers who, for the most part, agreed with the magazine’s view that homosexuality presented “intrinsic disadvantages for the [homosexual] individual, disadvantages that would exist even in a tolerant society.”81 While tolerant bastions such as Playboy begrudgingly accepted homosexuality, other less liberal media outlets such as Time espoused its unhealthy nature. If editorial content offered a muted response to the issue, the tone of the advertisements was anything but. Blackbelt aftershave marketed itself as the scent for “men who don’t have to prove anything to anybody,” implying that only the strongest and straightest men could wear it.82 Advertising for Brut Cologne warned that if you had “doubts about yourself you should try something else.”83 The language used in health and hygiene advertisements reinforced a hyper-masculine identity that celebrated heterosexuality. Sports endorsement remained relatively unchanged in the 1970s, but satirical content disappeared from the periodicals as the periodicals increasingly featured traditional and non-traditional sport. An article in Esquire nostalgically interviewed former sports celebrities such as Charles Atlas, who still thought that youth were “in rotten shape” and missed receiving letters from “boys who wanted to get strong so they could punch out the Japs,”84 as he had during the Second World War. Meanwhile, advertisements continued to link sport and grooming, reinforcing the exclusionary nature of health through references to both sexual desirability and the homosocial arena of sport. Companies such as Dep

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For Men used the authority of the sports celebrity to market their products, and the resulting advertisements linked the success of figures such as American football star Mike Curtis with use of the correct hair product, exclaiming, “Style is what makes the great ones great!”85 Similar Dep ads featured football player Mike Battle and golfer Bob Lunn.86 In 1975, an advertisement linked sports car racing with cigarettes. Next to the image of a speeding race car the text read, “After going 212 m.p.h., he’s not about to smoke a boring cigarette,” while the slogan “Viceroy. Where excitement is now a taste” linked the thrill of race car driving with smoking.87

Conclusion The 1970s represented the culmination of earlier exclusionary trends in advertising as the hegemonic masculinity of the era was reflected in popular channels of health, such as marketers’ visualizations in Playboy and Esquire. Fear-driven propaganda and consumerism influenced many facets of the Cold War era, including how health was depicted. Guided by critical theory and gender studies, I addressed the shaping of masculine stereotypes in the United States of the Cold War era. While the continued homophobic undertones of societal discourse indicate that these culturally constructed images produced tangible consequences for men, adequately addressing individual experience is outside the purview of this study. It is possible to draw conclusions about the dominant message of the advertisements – for instance, that the celebration of heterosexual virility reflected the idealization of sexual prowess – but not to address individual responses to specific advertisements. Instead, it is my hope that an analysis of a dominant visual discourse will form a piece of a larger mosaic about the influential nature of visual media and consumer culture. Advertisements, often reinforced by editorial content, offered various ways for men to control their bodies. Two dominant images appeared within masculine health discourse – the womanizer and the sportsman – both of which excluded homosexuality. While many scholars have recognized the power of the medical gaze, few have realized that its authority can transcend the expert.88 The ads from Playboy and Esquire use the legitimacy of medicine and health to ply their wares. The result is the strengthening of heterosexuality as a masculine ideal and the patriarchal nature of society. In this instance, popular culture draws upon normative social identities and provides another layer to the discourse of health. During the Cold War era, the

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dominant message of that discourse regulated homosexuality and the ads were no different. Importantly, the visual aspect of the advertisements makes for a stimulating message. I believe this is an important topic of study as the subversion of health by popular culture has widereaching consequences. As our society progressively moves toward a ­visual bias, it will become increasingly important to recognize and understand the power of these media. Even today, the relationship between health, hygiene, and consumer is tenuous as products continue to rely on sexual images and sports heroes to sell products while Western society has apparently become enamoured with health. What is the role of the expert in a world where infomercials and magazine ads promise all manner of remedies?

notes   1  Fashion editor Sara Buys wrote an article to dispel the myth that Marilyn Monroe was a size sixteen. Through an examination of clothing actually worn by Monroe, she placed her size at modern size eight for the majority of her career and argued that she never eclipsed a size ten. Sara Buys, “Was Marilyn Monroe a Size 16?,” The Times [U K ], 11 April 2009.  2 Bordo, Unbearable Weight; Giordano, Understanding Eating Disorders, 23–7; Rosen and Ramirez, “A Comparison of Eating Disorders,” 441–9; Macsween, Anorexic Bodies.  3 Bordo, Unbearable Weight, 15.  4 Coney, The Menopause Industry, II, 11–12; Martin, The Woman in the Body, xxiv–xxv, 42, 174.   5  For further reading on women’s body issues, see Bordo, Unbearable Weight; Giordano, Understanding Eating Disorders, 23–7; Rosen and Ramirez, “A Comparison of Eating Disorders,” 441–9; Macsween, Anorexic Bodies. For the gendering of medical discourse, see Metzl, Prozac on the Couch.  6 Shilling, The Body and Social Theory, 30–1, 39, 98–100; Jefferson, “Muscle, ‘Hard Men’ and ‘Iron’ Mike Tyson,” 77–98; Mishkind et al., “The Embodiment of Masculinity,” 37–52.  7 Scott, Gender and the Politics of History, 17.   8  For further discussion of Playboy and Esquire as sites of masculine identity construction, see Edwards, Men in the Mirror, 82; Osgerby, “A Pedigree of the Consuming Male,” 73; Benwell, Masculinity and Men’s Lifestyle Magazines, 7.   9  Molyneaux, “In Sickness and in Health,” 22, 52–5. 10  Hall, “Encoding / Decoding,” 134. 11  Ibid., 131.

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12  Roland Barthes, “The Rhetoric of Image,” 46–7. 13  Similarly, Gillian Rose argues that the disconnection between image and “textual performance” is a common occurrence; however, while Mitchell’s efforts are meant to avoid placing an overemphasis on the image, Rose wants academics to remember that “visual images can be powerful and seductive in their own right.” Similar to Hall and Mitchell, Rose believed in the importance of studying the “dialectical struggle in which opposing terms take on ideological roles and relationships at different moments of history” and that a contextual awareness is important when discerning the dominant message. Mitchell, Iconology, 9, 44; Rose, Visual Methodologies. 14 Connell, Masculinities, 73. 15  The legality of homosexual activity varied state by state. In 1961 Illinois was the first state to repeal sodomy laws. Connecticut followed suit in 1969. In 2003 the US Supreme Court ruled that the constitution protected private sexual conduct, a decision that invalidated the remaining statebased sodomy laws. See D’Emilio, Sexual Politics, Sexual Communities, 42, quoting from US Senate, 81st Cong., 2d sess., Committee on Expenditures in Executive Departments, Employment of Homosexuals and Other Sex Perverts in Government (Washington, D.C., 1950), 3–5. 16 Cuordileone, Manhood and American Political Culture in the Cold War, 67. 17 Connell, Gender and Power, 37. 18  Allyn, “Private Acts / Public Policy,” 406, 412. For further information on Kinsey, see Irvine, Disorders of Desire, 31–66; Bullough, Science in the Bedroom, 168–85. 19 D’Emilio, Sexual Politics, 37. 20  McCarthyism claimed that homosexuality was a reflection of poor morals and the breakdown of the traditional American family. D’Emilio, Sexual Politics, Sexual Communities, 257; Cuordileone, Manhood and American Political Culture in the Cold War, 64–6. 21 D’Emilio, Sexual Politics, Sexual Communities, 37. 22  Ibid., 247. 23 Katz, The Invention of Heterosexuality, 106, 108; D’Emilio, Sexual Politics, Sexual Communities, ix. 24 D’Emilio, Sexual Politics, Sexual Communities, 215; Peter and Barbra Wyden, Growing Up Straight: What Every Thoughtful Parent Should Know about Homosexuality (New York: Stein and Day, 1968); Lawerence Hatterer, Changing Homosexuality in the Male: Treatment for Men Troubled by Homosexuality (New York: McGraw-Hill, 1970). 25  Osgerby, “A Pedigree of the Consuming Male,” 69.

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26  Dworkin and Messner, “Just Do … What?”, 341–3. 27  Schacht, “Pitch,” 555. 28  Curry, “Fraternal Bonding in the Locker Room,” 126–7. 29  Connell discussed the distancing of sport and homosexuality in “A Very Straight Gay: Masculinity, Homosexual Experience, and the Dynamics of Gender.” With “Machismo, Misogyny, and Homophobia in Male Athletic Subculture,” K.B Muir and T. Seitz provided a case study of homophobic attitudes in sport through an examination of American collegiate rugby. They found misogyny, machismo, and homophobia embedded in sporting culture and argued that the communal sporting atmosphere enhanced ­ritualistic exclusion. Connell, “A Very Straight Gay,” 735–51; Muir and Seitz, “Machismo, Misogyny, and Homophoba in Male Athletic Subculture,” 303–27. See also Messner, Power at Play; Klein, “Little Big Man.” 30  R. Eugene Holemon, M D , and George Winokur, M D , linked effeminacy with homosexuality in 1965. R. Eguene Holemon and George Winokur “Effeminate Homosexuality: A Disease of Childhood,” American Journal of Orthopsychiatry, 35, no. 1 (1965): 48–56. Kimmell discusses the need for men to prove their masculinity through a ritualistic rejection of femininity through displays of dominance. He argues that “the rules of manhood” intrinsically lead to a homophobic society as men’s fear of emasculation drives violent acts. Kimmel, “Masculinity as Homophobia,” 133, 135. 31  See endnote 3. 32 Connell, The Men and the Boys, 69–71, 186. 33  Dworkin and Messner, “Just Do … What?” 341–61. 34  In his introduction to the first issue of Esquire, founder Gingrich stated that his new magazine would “never intend to become, by any possible stretch of the imagination, a primer for fops.” Esquire (Autumn 1993–94), cited in Osgerby, “A Pedigree of the Consuming Male,” 6; Brezeale, “In Spite of Women.” 35 Kimmel, Manhood in America, 126; Miller, Bunny: The Real Story of Playboy, 39; Osgerby, Playboys in Paradise, 121–2, 151–2. 36 Benwell, Masculinity and Men’s Lifestyle Magazines, 7. 37 Connell, The Men and the Boys, chap. 5. 38  Ernest Havemann, “The Sex Institute,” Playboy (September 1965): 139. 39  Jules Archer, “Don’t Hate Yourself in the Morning,” Playboy (August 1955): 21. 40  Archer, “Don’t Hate Yourself,” 21. 41  Playboy (December 1955): 4. 42  Playboy (December 1955): 4. 43  Playboy (December 1955): 4.

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44  Playboy (December 1955): 4. 45  Esquire (July 1955): 3 46  Esquire (December 1955): 274. 47  Esquire (December 1955): 274. 48  Esquire (December 1955): 55. 49 Bederman, Manliness and Civilization, 174–8, 191. 50  Ibid., 205–6. 51  Octavus Roy Cohen, “This Was Baseball,” Esquire (October 1955): 99–100. 52 Connell, The Men and the Boys, 86. 53  For more information on Babe Didrikson, see Babe Didrikson Zaharias, The Life I’ve Led: My Autobiography (New York: Barnes, 1955); Cayleff, Babe. 54  Gallico, “This Man’s World,” Esquire (March 1955): 48. 55  Ed Pazdur, “Playboy’s Ring Preview for the Year,’ Playboy (February 1944): 31–2. 56  W.C Herne, “Young Fighter,” Esquire (July 1955): 39, 107–8. 57  Ibid., 107. 58  Archer, “Don’t Hate Yourself in the Morning,” 22. 59  Ernest Havermann, “The Sex Institute,” Playboy (September 1965): 164. 60  Havermann, “The Sex Institute,” 152. See also Wardel B. Pomeroy, “What is Normal,” Playboy (March 1965): 97, 174–5. 61  Playboy (December 1960): 64. 62  Playboy (December 1960): 37. Also appearing: Playboy (November 1960): 41; Esquire (November 1960): 38; Esquire (December 1960): 62. 63  Playboy (December 1965): 38; Esquire (September 1965): 50. 64  Playboy (November 1965): 35. Also appearing: Esquire (December 1965): 24. 65  Esquire (January 1965): 4. Also appearing: Esquire (March 1965): 4; Playboy (January 1965): 13; Playboy (March 1965): 12. 66  Playboy (September 1965): 201. Smaller version: Esquire (September 1965): 58; Playboy (November 1965): 54. 67  Playboy (December 1965): 57; Esquire (December 1965): 99. 68  Alcohol’s unhealthy nature was prominent in mid-century medical discourse. Of note is E. Morton Jellinek’s work on alcoholism. E. Morton Jellinek, The Disease Concept of Alcoholism (New Haven: Hillhouse, 1960). See also Booth Page, “E. M. Jellinek and the Evolution of Alcohol Studies,” 1619–37. 69  Esquire (March 1960): 79. 70  Playboy (February 1960): 99. 71  Charles O. Puffer, “Hunting for the Urban Man,” Playboy (October 1960): 74–5, 135–6, 139.

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72  Playboy (April 1960): 84. 73  Esquire (January 1960): 141. Also appearing: Esquire (July 1960): 135. 74  Esquire (May 1960): 152. Also appearing: Playboy (May 1960): 12. 75  Esquire (November 1965): 100. 76  Esquire (November 1965): 100. 77  Esquire (December 1965): 206, 207, 250, 251, 254. 78  Playboy (June 1965): 175. Similar advertisement appearing: Playboy (September 1965): 56; Esquire (December 1965): 294. 79  This link was stressed in mid-century self-help literature. Wyden, Growing Up Straight; Hatterer, Changing Homosexuality in the Male. 80  Playboy (February 1970): 48. 81  Playboy (February 1970): 48. 82  Playboy (March 1970): 195 Also appearing: Playboy (May 1970): 1. 83  Playboy (November 1970): 197, 218. Also appearing: Playboy (October 1970): 220. 84  Esquire (April 1970): 126–9. 85  Playboy (May 1970): 18. A similar ad appeared in the May 1970 issue Playboy that proclaimed: “Style. It’s the difference between the ordinary and the extraordinary. Where your hair’s concerned, style means combing it a new way that’s all your own. Giving it that thick, manly look. A healthy luster like Curtis.” Playboy (May 1970): 21. 86  Playboy (March 1970): 83; Playboy (September 1970): 170. 87  Playboy (January 1975): 29. 88  Some interest exists regarding the relationship between consumerism and medicine; however, the majority of these works focus on the commercialization of medical science. I would postulate that the subversion of the ­authoritative lens for non-scientific products is the continuation of this practice. See Apple, Vitamania; Tomes, “The Great American Medicine Show Revisited,” 627–63; Herzberg, Happy Pills.

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11

Educating Doctors about Obesity: The Gendered Use of Pharmaceutical Advertisements W e n dy M i t c h i n s o n The photo is of a friendly doctor and a well-dressed overweight woman sharing a laugh, part of an advertisement for Dexedrine (dextroamphetamine), an appetite suppressant used as a diet aid in the control of obesity. It is a subdued ad in that it does not portray the “patient” as a supplicant. She could be any woman. But the text makes clear that the patient does have legitimate needs – for the “encouragement” of her physician and the “help” of Dexedrine. The drug will not only control her appetite for the entire day but also help her overcome the “lethargy” often seen as a problem with overweight patients and in doing so renew her interest in activities other than eating.1 Advertisements such as this were, and are, part of the content of the Canadian medical journals read by physicians, and they played a part in educating them about the products available to assist them in treating their patients for a wide spectrum of ailments. Most of the historiography on medical education, however, has focused on the formal training received by physicians and overlooked the role played by informal venues of education after graduation from medical school, such as product advertisements or detail men.2 The focus of this study is the pharmaceutical advertisements for diet aids used in obesity treatment that appeared in the Canadian Medical Association Journal (c m a j ) and the Canadian Doctor from the late 1940s to 1980.3 These years were significant ones for the country, its citizens, and physicians. The immediate post-war period brought with it economic prosperity for many and a sense that modernity had arrived. In medicine,

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many of the contagious and infectious diseases on which health care had focused in the past had been eradicated or controlled, leaving chronic health problems linked to lifestyle changes as those with the highest incidence. Such a shift was part of a larger move from a society in which unpredictable dangers loomed to one that was risk averse.4 In the context of the Cold War, pundits worried that Canadians had become soft and their life too easy. As sport guru Lloyd Percival declared in the early 1950s, “Our Flabby Muscles are a National Disgrace.” By the 1960s, the Royal Canadian Air Force’s 5BX exercise plan for men, and later the 10BX exercise plan for women, had become nationally and internationally popular. Building on the increasing interest in ­fitness, the government in the early 1970s responded by supporting ParticipA C T I O N , a program to encourage Canadians to become more physically active.5 If they did not, the fear was that the number of unfit and overweight Canadians would increase. Diet pills could help address both fitness and weight concerns. Dexedrine advertised itself both as an appetite suppressant and as a stimulant to exercise.6 Obesity was a significant focus of concern in post-war Canada. Many practitioners viewed it as a consequence of living in a society in which food was abundant, processed food dominated, and the collective sweet tooth could be and was being satisfied. Physicians considered the impact of obesity on health to be extensive and disturbing and designated it as a risk factor in chronic diseases such as diabetes and liver and kidney diseases. While most of the medical literature considered overeating as the primary cause of obesity, the manifestation of eating and the needs of patients associated with it were seen as gendered, as were the goals of health. Good health enabled men and women to pursue specialized roles in society and meet the demands of gendered citizenship. The perceived decline in health suffered by people who were obese was accompanied by a decline in the level of citizenship they could offer, a form of biological citizenship serious enough for government and medical intervention.7 As discussed in chapters 1 and 2 by Patricia Reeve and Marjorie Levine-Clark, a central aspect of that citizenship was the ability to work. In the middle decades of the twentieth century, advertisements in the medical journals depicted work in highly gendered ways – paid employment by men and predominantly domestic work by women. Together, gendered health and work underlay the “normal” family that was the perceived ideal societal unit of the time. Historians of medicine have noted the growing role of pharmaceu­ tical companies in medicine in the twentieth century through the

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increasing use of drug therapy for a myriad of medical conditions.8 Canadians’ awareness of the power of medical drugs came with the discovery of insulin in the 1920s by doctors Banting and Best at the University of Toronto.9 It was a national achievement of which to be proud and brought home the realization that a new era in medicine was beginning. Insulin was followed by penicillin, sedatives, antidepressants, antipsychotics, blood pressure drugs, cancer drugs, and oral contraceptives, to name a few. The rise of big pharmaceutical companies, the fascination of medicine with the possibilities of new drugs on the market, and the excitement of consumers that their physical or psychological problems could have pharmacological solutions (if not a cure) was the context for the emergence of drugs for obesity once it became a health issue increasingly dealt with by physicians. As Nancy Tomes has made clear for the American context, the cornucopia of drugs practitioners could access and offer to their patients reflected the consumer culture of the larger society.10 By the 1940s, estimates of the proportion of Canadians who were overweight ranged from sixteen to thirty-three per cent of the adult population.11 By the end of the 1960s, family physicians commented on how obesity had become one of the “commonest diagnoses” in their practices. In 1970 it was estimated that twenty per cent of Canadians were obese, and three years later the figure was put at thirty per cent.12 Such estimates were based on local rather than national studies, and the definition of obesity varied from study to study on the basis of height, age, and sex. Dieting produced the most significant treatment response, often aided by the use of drugs to curb appetite and alter mood so that patients would keep to their diets and successfully lose weight. Such drugs became increasingly popular and numerous, making it difficult for physicians to keep up with which ones were available, their chemical composition, their safety, their efficacy, and their suitability for any particular patient.13 Historians have long turned to advertisements and other visual material in popular magazines to interpret everyday life in the periods they study.14 For medical historians, advertisements in medical journals impart information about the changing nature of treatment and the continuing education of physicians.15 Advertisements also provide insight into how particular conditions were gendered and how advertising used gender to appeal to physicians. Advertisers did not create a gendered social perspective per se but applied an existing one to a specific

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situ­ation (health) and audience (physicians). Advertisements depict the ideals of society (not necessarily the average) to sell products. Compared with the advertisements from Esquire and Playboy that Thomas Wendelboe examines in chapter 10, however, pharmaceutical advertisements for diet aids do not push the ideal too far from normative reality. Unlike those for the popular magazines, their audiences were specialized – only practitioners or others in the medical profession. As in the United States, patented drugs in Canada developed and sold by what were known as ethical drug companies tended not to be advertised directly to consumers in the early decades of the century. Eventually these companies were prohibited from doing so. For example, in 1934 the sale of remedies for certain diseases, such as cancer, directly to the public was prohibited.16 In 1941 barbiturates and amphetamines were placed under prescription through the Food and Drugs Act in an effort to lessen their use by drug users and others.17 Prescription drugs could not be advertised directly to the public. The placement of amphetamines under prescription control was significant because amphetamines would dominate many of the diet pills advertised in Canada from the late 1940s into the early 1970s. Similarly, dinitrophenols were also placed under prescription control, probably because of the danger they posed to health, even though they were used as weight loss drugs. 18 Over-the-counter products, however, such as Ayds (benzocaine, a local anesthetic that lessened the perceived taste of food and was known as the diet candy), could be and were advertised vigorously to the public d ­ irectly, being deemed non-addictive and not a significant threat to health if taken. Popular magazines occasionally published articles informing readers about new prescription drugs but, unbeknownst to readers, some of these articles were ghost written for the drug companies. Drug companies could place generic ads to focus on the “wonder” of available drugs, creating expectation in both lay people and physicians about the ability of drugs to treat many ailments. The companies also encouraged sympathetic physicians to write articles in the professional journals.19 Advertisements for prescription obesity drugs in the medical journals supported and encouraged the partnership developing between practising physicians and drug companies and give us a sense of what advertisers thought would appeal to physicians. For example, they depicted ideal patients as being in control of themselves and their bodies, able to follow a healthy lifestyle and, consequently, able to reach a normative

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weight. Such advertisements were not created to appeal to or to inform the public, only medical professionals. By making physicians part of the consuming society of these years, pharmaceutical companies could reach those who would eventually consume their specific products.20 Prescription drug advertising was becoming big business and, as the medical drug market increased to meet the demands of controlling chronic health problems, it became significant for its influence in keeping physicians up to date. Certainly studies indicate that practitioners have been less than critical about the advertisements or their reliability. Indeed, until recently the Canadian Medical Association (C M A ) and its journal have historically defended the pharmaceutical industry.21 That industry has included Canadian companies, but the majority of the most significant drug companies have been foreign owned, many of them being based in the United States. The Canadian subsidiaries by 1980 controlled ninety per cent of Canada’s drug market. They are a significant pressure group, especially when they are in tandem with the C M A . The result is that the approval of most drugs in Canada was based on development, testing, and approval elsewhere. Although Canada has its own approval procedure, it seldom expects or asks for evidence other than what already exists.22 In the United States, federal power over prescription drugs came in 1951. In Canada, the Restrictive Trades Commission reported in 1963 that for all intents and purposes the American patent system determined how the pharmaceutical industry in Canada worked. In 1963, as well, however, the manufacturers of new drugs had to submit before clinical testing and before marketing the “proof” of a drug’s ­safety and efficacy. 23 Given that most of the pharmaceutical companies were based in the United States or elsewhere (for Quebec often the companies were French), it is not surprising that there was little Canadian-specific content in the advertisements. The ads were somewhat generic except for the occasional ads that referred to studies done in Canada or the need to respond to a Canadian content.24 Interestingly, the ads themselves were seldom the same as those in American medical journals. While in general the Canadian drug legislation often reflected the American legislation or was at least in tandem with it, it was not always the case. Whereas the United States placed minor tranquilizing drugs on its prescription list in the mid-1950s, Canada did not do so until 1959. Until then it was up to each province to decide if they would be over-the-counter drugs or not.25 Contexts were not always identical and neither were decisions. In the early 1960s the United States

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rejected thalidomide; Canada did not. Even when legislation was on the books it was not necessarily implemented. The 1953 Food and Drugs Act was detailed about the act’s power over advertisements but in 1961 it was admitted that the Food and Drug Directorate had never interfered with advertisements addressed to medical professionals.26 Advertisements for obesity drugs (and most other products) were and are usually composed of two parts: images and text. Drawings, cartoons, and photos were the hook to get the physician to look f­ urther and read details about the various drugs. At times, the visual components were stylized, at others, highly representative. Some advertisements were much more sophisticated than others in terms of the amount of text offered and the detail of the visuals. Those in the c m a j , for example, were more sophisticated than those in Canadian Doctor, unless the same advertisement was placed in both journals. Some companies advertised in different journals, perhaps as a matter of cost, although the main pharmaceutical companies tended to advertise in many.27 What emerges from a general overview of the c m a j and Canadian Doctor is how many pharmaceutical diet aids were available, how many advertisements were produced for these products, and how often the advertisements were repeated. The ads began to appear in the late 1940s, increased in number throughout the 1950s and 1960s, and then decreased in the 1970s. The decline in the number of advertisements in the 1970s did not necessarily reflect a decline in the popularity of diet aids but rather the consolidation of the market to fewer products that dominated it. This chapter is essentially a case study of drug advertisements for the treatment of obesity directed to physicians. It argues the importance of such ads as a source for historians of medicine, as a way of understanding the relationship between practitioners and the pharmaceutical industry and the way in which the latter appealed to the former and how the patients, the ones who would be prescribed powerful drugs, were depicted as being in need of both physicians and the pharmaceutical industry. Underlying the chapter are three approaches. The first is a gendered analysis. Certainly the pharmaceutical industry played on social and cultural norms of women and men in their advertisements. Second, in looking at the ads through the lens of gender, I have been influenced by the linguistic turn, reflected in the deconstruction of meaning in both the visual and the textual aspects of the advertisements. Last, awareness of the affective turn acknowledges the intended emotional impact of the ads on physicians.

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E d u c at i n g D o c to r s t h r o u g h A dv e rt i s e m e n t s Once physicians graduate from medical school and become practitioners they realize how basic and limited their training has been. It is an ongoing complaint of practitioners that education in medical schools does not prepare students well for actual practice. In the period when doctors practising from the 1940s to 1980 were trained, obesity and nutrition were subjects that formal medical education addressed only minimally. In addition, although they were taught the basics of pharmacology, once in practice, physicians faced the challenges of keeping abreast of new pharmaceuticals and their applications.28 In the period from 1951 to 1961, more than 4,000 new prescription products became available in the United States. Even if not all were available in Canada, the figure suggests the rate at which pharmacological knowledge alone was increasing.29 The result was that medical students were becoming vociferous about the overwhelming information they had to  learn.30 Uncertainty was increasingly part of a doctor’s regimen.31 Relying on detail men but also the drug ads was a way of keeping up, and the pharmaceutical companies were more than willing and financially able to become a partner in this education.32 Indeed they had a long history of doing so. As early as 1935, the Ontario Medical Association Bulletin acknowledged the “necessary” funds provided to the journal from Ayerst, McKenna & Harrison (Pharmaceutical and Biological Chemists) to produce the journal.33 Advertisements paid by pharmaceutical companies increasingly kept medical journals solvent. Certainly the companies could afford to be generous. The manufacturer of Probese (amphetamine sulphate and thyroid U S P ) advertised in 1952 that it had sold 26,000,000 of its tablets in Canada.34 They may not all have been prescribed for obesity but nevertheless it confirmed the growing significance of pharmaceuticals and the money being earned by the drug companies. Such advertisements existed to sell products and they did so in ways to appeal to their physician-readers: they emphasized the safety of the product being offered and the trustworthiness of the manufacturer; they referred to the scientific nature of the research that went into the discovery and production of the drug; they created a partnership between the pharmaceutical company and physicians through a common language; they underlined medicinal specialization by reflecting it in different drug treatments for different types of patients; and they left physicians with the final decision so that the doctor–patient relationship would be seen to remain in the hands

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of the medical practitioner. As Barbara Millar has noted, “The physician is the focal point of the patient’s expectations, industry’s promotion, pharmacist’s business and government’s concern” and central to that was and is the drug prescription.35 The educational function of such ads was significant. General practitioners were the front-line treatment providers for all sorts of chronic problems, such as obesity. Underlying the advertisements was the tone that practitioners could not keep up with the various medications on the market. Doctors knew it and most did not seem fazed by the growing relationship between the medical profession and the pharmaceutical companies.36 A study on appetite suppressants found that in Ontario general practitioners relied more often on the promotion of the drug company than professional sources (fortyeight per cent compared with five per cent).37 Given the lack of information at doctors’ disposal about the various drug treatments available and the powerful nature of appetite suppressants, safety was a key enticement to get physicians to consider prescribing a specific drug. In the late 1940s, a Dexedrine ad assured readers of the drug’s general safety, quoting from a recent Journal of the American Medical Association article that stated that “prolonged” use in studies resulted in “no evidence of toxicity … [and] no evidence of deleterious effects of the drug.” Little specific information was provided but, by quoting a highly regarded source, the advertisement reassured physicians that they were dealing with a safe and reputable drug.38 Another way of convincing physicians of the safety of a product was to emphasize that it could be taken by people who were vulnerable in some way. Pregnant women were such a group, both because society viewed them as weaker than men and because whatever medication they ingested could have an impact on the fetus. Although medical literature in the 1950s and 1960s often depicted the womb as quite resilient to drugs such as tranquilizers, obesity drug advertisements used the more popular notion of a pregnant woman’s vulnerability to emphasize safety claims.39 Doctors also worried about the dangers of already overweight or obese women becoming pregnant and of any woman putting on too much weight during pregnancy and, consequently, saw them as a market for weight control.40 This category had long been one in the obstetrical literature, but it also entered the writings on obesity. Children were perceived as another vulnerable group. The manufacturer of Probese T D Mild advertised that it contained only half the thyroid medication of the “normal” Probese T D and two-thirds the amphetamine. Designed for the treatment of children, it reflected a growing concern about

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youngsters being overweight that was providing drug companies with a new niche market.41 Other vulnerable groups were those who were overweight and suffering from diabetes, hypertension, or heart problems. In the years under study, men were the focus of concern about hypertension and heart disease, and of note men in executive positions; the medical literature considered these men to be more risk for coronary disease when they put on weight than other men or women.42 Although claims about the safety of diet drugs continued, by the mid1960s they were narrowing. The small print in a Tenuate (diethylpropion hydrochloride) ad warned that although it was safer than products containing amphetamines, physicians needed to be selective in prescribing it to pregnant women in the first trimester. Ads for Ponderal, containing fenfluramine hydrochloride, made clear that the drug should not be used by pregnant women at all.43 Such warnings put ­doctors on notice that their patients must use the drugs responsibly and that physicians needed to be aware of their patients’ general health and not just their obesity. These warnings also protected manufacturers from any liability if the drugs were used by contraindicated patients. The detail was, in part, a reaction to the societal concern about the ­increasing use of illegal (non-medical) drugs, which led to the 1972 federal investigation into the non-medical use of drugs (the Le Dain Commission).44 “Proof” of the drug companies’ claims was in the detail provided and the appearance of honesty. By listing side effects, the companies provided the necessary detail and gave the appearance of being open about possible consequences of taking their products. As the Dexedrine advertisement from the late 1940s illustrates, statements about side effects could be general. By the 1960s, however, listing side effects and warnings in small print became much more elaborate in part because research on the side effects of various drugs such as amphetamines was increasingly being published in the medical journals. Detailed listing was a way for pharmaceutical companies to keep up with the literature and to appear open and concerned.45 Advertisements for Dexamyl (Dexedrine sulphate and amobarbital) and Dexedrine listed adverse reactions of “overstimulation, restlessness, insomnia, g.i. disturbances, diarrhea, palpitation, tachycardia, elevation of blood pressure, tremor, sweating, impotence and headache.” It was more difficult to predict side effects for products that combined drugs, such as Dexamyl. Manufac­ turers of these products made clear, however, that it was the specific drug combination that determined efficacy and also differentiated one

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product from another.46 Side effects were understandably more detailed when the advertisement was for a pharmaceutical product that addressed obesity or excess weight in someone who was in a vulnerable category. At that point, the details could read like a medical text.47 But the companies’ willingness to list side effects varied from ad to ad (not product to product), and the size of the advertisement appears to have dictated the level of detail. Some ads were cleverly designed and placed the list of potential side effects on a page adjoining the main advertisement. Others, like those for Prelutal (phenmetrazine hydrochloride), blamed the patient for experiencing side effects, referring to the “problem obese” who did not seem to respond to “routine therapy” in a satisfactory way. The text also listed what were often seen as the side effects of the drug – “irritability, insomnia, headache and gastric distress” – and insisted these were not in fact caused by the drug treatment per se but rather by “emotional distress caused by food withdrawal,” which Prelutal could overcome through the “tranquilizing action of promazine.”48 Although the companies were seemingly acting in a responsible manner and one that would appeal to practitioners, the context for doing so was perhaps less than altruistic. In the United States, Senator Estes Kefauver and his congressional investigation of the companies placed pharmaceutical advertising and the lack of listing side effects under scrutiny in the early 1960s. The reaction of the companies was to provide some listings, and certainly those selling to the Canadian market were required to do so.49 Underlying claims about safety and side effects was the appeal to doctors’ belief in science. A series of cartoons advertising Probese and Dexobese (dextroamphetamine) were headed by the caption “Famous because ….” One depicted a very skinny and hairy man, intended to be Archimedes, sitting in an overflowing bathtub. There is no connection between Archimedes and obesity, but placing a famous classical scientist in the advertisement implied the scientific credibility of obesity treatment with Probese or Dexobese. More direct and specific references were made to modern scientific studies that supported the claims of the drug being advertised. In introducing Pre-Sate (chlorphentermine hydrochloride), a nine-page advertisement detailed the results of animal experiments. The first page showed a picture of a cat looking at the viewer, with a lead around its neck and an electrode attached to its head and three jagged lines beneath to suggest brain waves. The thrust of the ad was to suggest that there was something new on the market, a product that would not stimulate the control of hunger but would “satiate”

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the hunger itself. In the cat experiments Pre-Sate controlled appetite even when doing so went against the well-being of the cat; that is, the drug produced the sensation of fullness in both starved cats and nonstarved cats so that even the former refused food. The ad is full of photos of cats refusing food. Stressed was the “extensive clinical evaluation” that had gone into the testing of Pre-Sate. Physicians could be assured, then, that modern science was behind it. With a long list of studies and an exhaustive list of precautions and side effects, the ad reads like a ­research paper.50 The voluminous detail in some of the advertisements assumed that the physician-reader understood all the references made. Whether or not that was so, the assumption was part of the script and made practising physicians part of the experimental side of medicine. The ads provided knowledge shared with a select group of people. They were a primer on specific drug use. While the companies giving the primer had a vested interest in presenting their products in the best possible light, they often addressed the physician’s concerns, such as the possibility of patient dependence on amphetamines or some other drugs being offered. Warnings in the ads noted that “careful supervision is advisable with maladjusted individuals,” a vote of confidence in the family practitioner’s ability to recognize such individuals and supervise them. The message was also vague enough to justify the failure of a drug to work as promised.51

A Crowded Market As the obesity drug world became crowded, marketers needed to help physicians distinguish their products from others. Sometimes they did so by differentiating between types of eaters, reflecting what physicians were learning through the general medical literature. An ad for Biphetamine (amphetamine and dextroamphetamine combination) and Ionamin (phentermine) epitomized the sedentary overeater with a drawing of a very obese woman, sitting at home and reading a mag­ azine entitled Love while eating chocolates (figure 11.1). The active overeater was depicted as an obese, middle-aged man in a suit and tie, eating a restaurant meal and gesturing with his left hand to make a point.52 His obvious status as a businessman, eating what appears to be a business meal, would have been sufficient reason to identify him an active overeater.

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Figure 11.1  Advertisements used gendered references with which physicians would be familiar. This ad was published in the c m a j 84, no. 9 (7 March 1961): 13. Used with permission under a non-exclusive licence issued by the Copyright Board of Canada in co-operation with the Artists Representation Copyright Collective.

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The gendered nature of the drawings made them more believable to their audience. Women were depicted as less active than men and often shown snacking throughout the day, whereas men working outside the home could not take time off to do so or would be criticized if they did. Ads often depicted men instead as night eaters, eating after they had returned home from the office. Another way of separating one product from another was to add something to it that others did not have. Adjudets (dextroamphetamine), an amphetamine-multivitamin lozenge, had a novel form and contents. It was referred to as a candy that was an appetite suppressant. The vitamins both served as a reminder to physicians that dieting could lessen nutritional intake and provided a solution to the problem in the same package as the appetite suppressant.53 By the mid-1960s, the approach of advertisers and their message to physicians became more muted. There were many reasons for this. Concern about drugs and their safety was heightened by the thalidomide tragedy in the early 1960s. Although Canada eventually took this drug off the market, Canadians wanted to know why and how it had been approved, especially when the United States had not allowed it.54 Added to this were concerns about the use of recreational drugs such as amphetamines. Marketers whose products did not contain amphetamines criticized the diet pills of their competitors that contained the drug. So strong was the worry about the use of amphetamine, both legal and illegal, that Canada banned it for diet use in 1972.55 The major reason, however, for the advertisements becoming more muted was that diet pills did not live up to the advertising hype. Too many patients did not lose weight or if they did they could not keep it off. Marketers began to limit their claims about what diet pills could accomplish. For example, ads for Pre-Sate emphasized its value for the short term by referring to its importance “over the vital first 30 days of diet.” Although the ad did not explicitly say that the drug could not be taken for longer, the image of a man’s face with thirty days on a calendar superimposed emphasized the point.56 Other advertisements admitted and reminded physicians of the high failure rate of people losing weight and keeping it off.57 Some stressed that, in addition to losing weight, patients needed to undergo “re-education” in their eating habits and “removal of underlying psychologic causes” for overeating. Drugs could not do everything.58 In the 1970s, these admissions of limitations became much stronger and more frequent. To lose weight, a Pre-Sate ad noted, overweight people not only had to be prescribed the drug but also had to determine why they

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ate and how to stop, set themselves realistic goals, avoid “crash diets,” educate themselves about food and proper diet, become more active, and learn to eat less (and eat the right food) permanently. If they could not, it was not the fault of the drug if they did not lose weight.59 In contrast to the content of ads in the 1950s, such admonitions made physicians face the complexity of obesity treatment and its likelihood of failure – a failure not of their making but the patient’s.

Gender and Advertisements The advertisements addressed themselves both to obesity and to lesser degrees of being overweight, the latter reflecting a general societal concern about weight and the persistent notion of an ideal weight for both men and women, but especially for women. Women were the consumers of the medical pill solution. They were prescribed far more anti­ depressants than men,60 they seemed to consult physicians more often than men, and when the issues of weight were central, they, more than men, were surrounded by advertisements about the ideal body being slender. A British study in the 1960s brought this home in finding that eighty-five per cent of prescriptions for amphetamines were for women and one-third of amphetamines were prescribed for weight loss. In the United States, seventy-five per cent of amphetamine diet pills were prescribed to women.61 As well, those who volunteered to be participants in obesity studies were predominantly women. As a result, the perception was that women dominated the population of the overweight and obese. Gendered messages could be quite strong in the visual element of advertisements in the period under examination. Women dominated most of the research studies of obesity, primarily because they seemed more willing to consult their physicians about their weight. One PreSate advertisement estimated that four out of five overweight patients were women and ascribed the cause to both physiological and sociocultural factors. In addition it argued that women’s basal metabolic rate was lower than men’s: their bodies did not expend as much energy in using food; that is, their bodies were efficient. In addition, women cooked for their families and, consequently, were constantly tasting food, a habit that increased their appetites and added to weight gain.62 While women predominated in advertisements for obesity drugs, they did not do so to the degree that the Pre-Sate figures would suggest. A sample from the c m a j of the 1950s contained twenty-two distinct ads: six depicted a female figure, four depicted a male figure, two depicted

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figures of both sexes, and a surprising ten did not include any human figure. A sample from the 1960s contained ninety-one distinct ads: thirty-eight depicted women, twenty-one depicted men, six depicted both sexes, and twenty-six did not include a human figure. In the 1970s, only seventeen distinct ads were found: four of women, three of men, two of both sexes, and eight with no human figure.63 The visuals of the products did not always include people. Sometimes they were quite restrained. An early ad for Probese A, B, and C simply had a text with a photograph of the bottles containing its pills. An advertisement for Dexedrine depicted a plate on which the text was printed and a fork, knife, and spoon on either side of the plate. Another Dexedrine ad showed a drawing of a broken fork with pasta wrapped around the fork’s tines. Both of these ads were full page with little text – just a simple message. In the latter case the message was “overeating is a bad habit – you can help your patients to break it with Dexedrine.” The point of producing various ads was to vary their appeal, to offset readers’ familiarity with them, so that they could not be overlooked.64 Advertisements about obesity presented value-laden assumptions of age, class, race, and gender. Most depicted middle-aged, middle-class, white individuals, a picture of what was perceived as the normative patient, with the respectability of a good patient, who could afford to purchase the pills. As some scholars have suggested, a society protects itself from the “monstrous” threat of “others” by ignoring those outside its chosen parameters, an issue that Mona Gleason and Anika Stafford ­explore in chapter 9.65 The advertisements certainly described and ­depicted those who were fat as outliers within the societal framework of the time. Unlike ads for products targeted to outliers on the basis of race, gender, or age, and to a lesser extent class, advertisements for weight control drugs were offering a way to eliminate the very characteristic that made some Canadians outliers – fatness. Dominating the advertisements that depict recognizable people is the middle-class respectability of the subjects. Seldom does a working-class person appear, at least judging by clothing, place of work, and home environment. All of the figures appear to be white. Neither fact should be surprising. Although Canadian physicians provided care to individuals from all classes and (depending on the location of their practice) were increasingly likely to have non-white patients, the advertisements were designed to appeal to physicians by depicting the practice that a  middle-class white physician was assumed to want or have. They also  targeted the group with which the pharmaceutical industry was

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concerned – paying customers. Diet drugs were not covered by any ­government plan, and poor and disadvantaged groups were not the ­preferred clientele. The gendered nature of the images was typical and thus familiar and non-threatening to the physician. Men were usually depicted as being at work or away from home and family during their work day. Seldom did an ad show a woman in paid employment. An advertisement for Dexetrine in a 1953 issue of the c m a j included a photograph of an obese man, dressed in suit, tie, and overcoat, putting his hat on a coat rack and gazing straight at the reader. He is clearly a businessman. In the text the effects of the drug were not even listed, only that “unpleasant effects are mild or absent.” Taking the drug would not interfere with the man’s work, and thus his masculinity, an important message at a time when men provided the major financial support for their families. Similarly an ad for Ionamin has a cartoon drawing of an obese man ­taking charge of his obesity by stepping “up” into a physician’s office (figure 11.2). In another Dexedrine advertisement published in the same year as the previous Dexedrine ad, a middle-aged housewife (recognizable by her apron) sits reading a book and eating a rather large cookie, with others piled on a table within reach (figure 11.3). The message is that her weight is the result of eating and that overeating does not have to be egregious to be harmful but can consist simply of snacking between meals.66 The busy businessmen are not blamed for their own obesity, at least not overtly, since they are not shown eating. The woman is. Women were also often presented as being more emotionally needy than men. A March 1955 Dexetrine advertisement contained a photo of a middle-aged woman, wearing an attractive dress, sitting at a small table in her home, talking on the phone. A television is nearby but not on, and she has what looks like a cup of tea or coffee, a compote dish filled with fruit, and a plate of something else to eat in front of her on the table. The text asks the physician, “Do you ever see patients like this one?” The woman’s name is Grace and in case the doctor cannot interpret the message of the image, the text makes it clear. Grace does not have much to do. Her children are grown and have left home and she is left at home, nibbling as she either talks on the phone or watches T V . The advertisement refers to Grace as a “type” of patient whom physicians would recognize. Dexedrine’s Spansule capsule with its “sustained release” action would help Grace overcome the temptations of “candies, snacks, and drinks,” which have led to weight gain that from the photo

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Figure 11.2  In this cartoon, the man is seen as active, entering the office of his physician, perhaps to consult about his weight. Advertised in the c m a j 89, no. 2 (13 July 1963): 30. Used with permission under a non-exclusive licence issued by the Copyright Board of Canada in co-operation with the Artists Representation Copyright Collective.

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Figure 11.3  This advertisement shows a woman, unlike figure 11.2, which depicts a cartoon man. The woman is sedentary, at home, and snacking. Advertised in the c m a j  69, no. 4 (October 1953): 463. Used with permission by Paladin Labs Inc.

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does not yet seem very significant.67 The perceived higher incidence of obesity in women than in men was deemed by the medical literature of the time to derive from the “frustrations and tensions” in women’s lives. Men apparently had more outlets to relieve those tensions. Women such as Grace did not.68 Another ad described a pensive-looking woman as “sad” and “depressed” because she could not find stylish clothes for her size 40 body. 69 In some ads the visuals were benign but the language less so. In a photo in an ad for Biphetamine-T, an overweight young woman looking at clothes in a store also seemed depressed about not being able to fit into a certain size. While the visual was somewhat sympathetic, the text was not in that it claimed the drug could provide “an emotional ‘lift’” to offset “self-indulgence.” Overeating (assuming this was the cause of her weight problem), then, was self-indulgence. At the same time the advertisement recognized the depression that led to obesity. Such people needed help to overcome the “tyranny of appetite.” The language is extreme but perhaps with the recognition that most diets did not work, the advertisement was presenting weight loss as a battle in which the physician needed to use all at his disposal.70 The idea that lack of availability of fashionable clothes could depress women and lead to overeating fit the notion of women’s lives as more limited than men’s. But the apparent pettiness of their frustrations reflected a medical literature that depicted women as culturally dependent and, as such, susceptible to moods.71 Women were simply perceived to be more psychologically fragile than men. The psychological “weakness” of women played into the way some drugs in particular were portrayed. Amphetamines, for example, were promoted as being significant in treating some psychiatric problems as well as diet aids. Indeed, the two came together when the obesity literature looked at the psychological issues behind overeating.72 Fashion, weight, and age seemed to be a trio tied together for women. Preludin (phenmetrazine) had an ad in which the visual was a drawing of two women in silhouette, one a slender woman kneeling before the second woman to hem her dress. Beyond the slender woman was a slender female mannequin. The second woman was shaped with a profile that was a continuous convex line from the neck to just above her knees. Behind her was a rather large mannequin showing a waist the actual woman no longer seemed to have. The hair styles of the two women and their clothing suggest a significant age difference, with the larger woman clearly being the older woman.73 It was a picture of “what might have been” being compared to “what was.” The message was clear: fat made a woman appear older.

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Men in advertisements were more often than not caught up in their business world, too busy to keep track of what and how much they were eating, revealing the middle-class orientation of the ads and their assumption that men’s lives were richer and more fulfilling than ­women’s. Rarely were men depicted as needy. They were overweight or obese as a result of focusing on business, not themselves. But the consequences could be dire in terms of health and also as a threat to their masculinity. Deborah McPhail discussed an Eskatrol (amphetamine) ad with a drawing of an obese white man wearing a suit who was sitting on a chair holding a giant fork upright between his legs. While the ad clearly was suggesting that his appetite was dominating his life, the positioning of the upright fork where an erect penis would be was, in her words, depicting him as being “castrated by his compulsive desire for food.”74 A 1956 Probese (T D and V M ) ad used four male silhouettes travelling from right to left across the page, with the profile becoming thinner until the last, very long-legged silhouette climbs up a stylized ladder. One can interpret the last man as an action figure, climbing for success (figure 11.4). The male executive was a familiar figure of the time and one with which practitioners would sympathize. An Ionamin advertisement subtly criticized the use of amphetamines in weight control drugs, noting that “well-adjusted people who talk business at mealtime are as subject to overeating as the neurotic for whom food is an emotional substitute. Yet the anorexiant suitable for the latter – often amphetamine – may be excessively stimulating to the busy executive.” The image is of a restaurant table after the customers have left. The dishes are dirty and on the tablecloth are written financial figures, indicating that a business meal had taken place. The specific focus on executives reflected increasing concern about the link between heart failure and  being overweight in such men. The text makes clear that the ­executive’s eating is not neurotic but is instead connected to his preoccupation with work.75 Unlike large women who could not find fashionable clothing to fit, the perennial suit of “respectable” men was a uniform that did not overemphasize their girth. Even if it did, the consequences were not the same as those for women. Dr L. Bradley Pett of the Department of National Health and Welfare referred to the  psychological association eating had for men. Eating increased “their feeling of being big or important.”76 Clearly the link between size and masculinity was somewhat different from that between size and femininity.

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Figure 11.4  In this drawing, the attitude toward men who were obese is clear: their obesity was a handicap that hindered their efforts to rise in their chosen career. Advertised in Canadian Doctor 22, no. 3 (March 1956): 73. Used with permission under a non-exclusive licence issued by the Copyright Board of Canada in co-operation with the Artists Representation Copyright Collective.

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Seldom were the overweight or obese ridiculed. In the 1960s, however, Ionamin / Biphetamine ads included a series of cartoons that appealed to humour, laughing gently at the predicament of those who were obese. One of the first was a drawing of a rather abstract but clearly obese man whose body slopes from a pointed head to the base of a large triangle, somewhere above his knees. Wrapped in a flowered towel labelled “hers,” he stands on a scale trying to gauge his weight. Unable to see over his protruding abdomen, he resorts to using a periscope. The cartoon is humorous because the situation is ludicrous. The man’s shape is ridiculous and unreal; he is a man but not a man, for what man would let himself get to the point of putting a fussy and feminine towel around himself? The implication was that overweight men undressed were slightly effeminate. Here the man had placed his private masculinity at risk by becoming obese; the man beneath the business suit not yet put on was vulnerable to ridicule. As Thomas Wendelboe argues in chapter 10, this was an era of the hyper-male ideal and the figure ­depicted is as far from that ideal as can be imagined. This ad made fun of the people the advertised product was supposed to help. Another cartoon showed a trampoline “expert” whose body is floating upward, unsurprisingly because it is shaped like a balloon. The man has lost control and needs medication to bring him “back from orbit.”77 The Ionamin / Biphetamine series included at least sixteen cartoons, only three of which depicted women, perhaps because the chivalrous mores of the time did not encourage making fun of overweight women, at least not in advertisements of products designed to help them. One of the three ads shows a rather curvaceous, but clearly overweight, woman ­trying to get the bottom part of a two-piece bathing suit over her hips. The text reads, “She may get another season’s wear out of it … with Ionamin.” Unlike in the cartoons of overweight men, presented as stylized blimps, the woman’s body is clearly sexed and, “despite” the weight, she is drawn sweet and attractive looking.78 Cartoon advertisements had serious messages to impart. A Probese ad in May 1950 coupled mirth with the deadly reality that could face the obese. The drawing shows an enormously obese man, looking sad, wearing only a large towel that barely wraps around him. He is holding a tape measure and noting how much his abdomen has grown. In the lower right corner of the ad is a happy angel, with wings, a cape flowing out behind, and a huge abdomen protruding downward. It is the same man, who has died and become a fat angel. The text provides mortality rates for obese men compared with those for men of normal weight: at

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fifteen to twenty-five per cent overweight, the difference is forty-four per cent; at more than twenty-five per cent overweight, the difference is seventy-five per cent.79 Being overweight imperilled health and life. Such an advertisement reinforced the medical literature that focused on the heart and other health issues facing men. The future was not usually presented as so dire. Rather, returning those who were overweight or obese to a normal life was the more familiar theme. The positive results of weight loss were depicted in “action” photos. One for Dexedrine shows an older woman in hat, suit, and heels walking along with a child who is gazing up at a balloon. The text makes it clear that the woman can now engage in “normal activity” because Dexedrine helped her overcome the inactivity that went with being overweight. The drug has given back “normality” to both her and her family.80 A Biphetamine ad in the mid-1960s showed an overweight, middle-aged man climbing the stairs with a little boy in front of him, presumably his son. The man cannot keep up with the child. It was one of a minority of ads that visualized a man in a somewhat domestic setting. The focus here is on what the man cannot do rather than what he can, but the advertisement holds out an active future for him if he can lose weight, and the fact that he is climbing stairs puts him in a more active mode than the woman who is simply walking.81 At times advertisements went beyond returning an overweight individual to normality. They seemed to promise an idealized state, more often for women than men. Not surprisingly, advertisements reflected the value system and the idealized body image of the times. One of the earliest cartoons in the Canadian Doctor appeared in the December 1949 issue. In the upper left-hand corner of the ad, a large woman, wearing a dress and heels, stands on a tall weight machine, which is breaking under her weight. In the lower right-hand corner is a larger, “realistic” drawing of a nude and curvaceous young woman, kneeling on the floor with her head cocked to one side and her hands behind her head so that her breasts are lifted up and visible. The fat woman is a cartoon figure to amuse the onlooker. The “normal” woman is depicted in a drawing of a real, albeit very idealized nude. The message was clear – obese women were somewhat laughable and by their weight had lost the ability to be desirable. Such advertisements directed their message to a predominantly male profession, and other ads for Probese and Dexobese in the 1950s continued to use the female figure in suggestive poses. A 1966 advertisement for Ionamin contained a photo of a lovely, young, and slender (some might say slightly anorexic) woman dressed in a

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fashionable outfit that accentuates how small her waist is. Beside her on a table is a plate of fattening small cakes. She has her head down, her gaze fixed on the food, and a gloved hand ready – it is unclear whether she is poised to take or to reject a cake. But the text is clear: Ionamin offered those who were obese resistance against overeating and “protection” from food withdrawal “reactions.” A young woman like the one shown in the ad actually would have had nothing to do with the product because Ionamin was for overweight people, not for people maintaining weight loss. She was there to get the physician-reader’s attention – she was the hook.82 All these advertisements reveal the power that concepts of gender had throughout these years at the normative level and as a stylized ideal. Normative gender roles were comforting in their familiarity. They did not challenge practitioners but instead allowed them to focus their attention on the drugs advertised. Gendered depictions in advertisements also informed diagnosis, reminding physicians of the difference between active eaters, sedentary eaters, night eaters, and emotional eaters, each often designated by a specific gender. Following a gendered element in diagnosis was gendered treatment, as drugs, their strengths, and their combinations were varied to counteract specific types of eaters. It was not that advertisements directed physicians to see emotional eaters as female, but that they depicted women when the emotional / psychological element appeared to be causative or at the very least symptomatic. In doing so, the advertisements appealed to the norms and prejudices of society, one of them being that women were more interested in their appearance than men (and that men, too, were interested in women’s appearance). And in many ways women were, in part because they lived in a world that saw their attractiveness as their entry to a successful life. For men, attractiveness was not as central because their suit-uniform sent out a message of success (albeit to various degrees). Largeness in men could be a sign of importance. Their Achilles heel in the obesity advertisements was their health.

A P at i e n t u n d e r C o n t r o l A significant message of obesity drug advertisements was the promise of giving control over eating to obese and overweight patients to enable them to be responsible for their weight. A wonderful ad in which the picture speaks the message is one of the few depictions of men in a nonbusiness setting in the 1950s. It is of a dapper, youngish man, slightly

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overweight, a bit “soft” looking, dressed in hat, chequered jacket, shirt, and tie, with a very fashionable scarf thrown around his chest and over his right shoulder. He is behind a supermarket buggy full of food and in his extended left hand is a cake. He looks straight at the reader with his right hand by his mouth, as if asking whether he should buy the cake or put it away. Only at the bottom of the page is the message confirmed: “Successful appetite control begins in the supermarket.” If the man can resist the temptation to buy the cake he will be on the road to lasting weight reduction. Only then does the reader discover that the advertisement is for Dexedrine Spansule, which would curb appetite at meals and in the supermarket. Interestingly, the typography makes no differentiation of the product name. It is a subtle advertisement in which the visual element predominates with the message a doctor wants to see – a patient who thinks before he buys.83 Being able to control what you ate was necessary to take weight off and to keep it off, and images of life after weight loss were of people eating a limited amount of food. Of course, from the pharmaceutical company’s perspective, control came first from the drug and only subsequently from the patient.84 Having a patient who was in control was a message physicians wanted and perhaps needed to hear. Given the failure rate of dieting on its own, anything that kept patients optimistic would enable them to keep to their diets. It would make life easier for both doctor and patient and make their relationship much more pleasant. Making dieting easier was the enticement of obesity drugs. Canadians learned about diet pills from their friends and popular literature. That widespread information and the emphasis on being slim expressed by general society encouraged some people to ask their physicians for prescriptions, an “easy fix” that became increasingly popular for both patient and physician. Advertisements “talked” directly to physicians in a respectful and subdued way that did not appear to usurp their role. Nonetheless, it is clear that the agency of the physician was being limited. The physician could and was encouraged to choose from among the different products that any one company offered him. In this way, pharmaceutical companies educated the practitioner and became the origin of drug lore and understanding. If, as many scholars have argued, the medicalization of society increased during these years, the group of those who controlled that medicalization broadened to include what has come to be known as “big pharma.” The ads assured the physician, however, that he was not simply a dispenser of drugs; in choosing the type and strength of the drug he made a “medical” decision. Drug ads in general tried to make a

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common cause with physicians. In doing so the pharmaceutical companies were and are able to make doctors into allies in their often-fraught relationship with government and consumers. Doctors are courted by the pharmaceutical companies from medical school throughout their years of practice. The relationship may be minor – a free lunch, free samples of drugs for their practices, gifts – but it does create a bond, as did the detail men who came to see physicians, and the promotional materials companies sent them.85 Ads could also be comforting, commiserating with physicians about patients who did not seem able to lose weight and became obstreperous as a result. Being told that most patients were unable to succeed in dieting reassured physicians that they were not alone, but at the same time what diet aids offered gave them some expectation that the situation was not hopeless. Ads deliberately acknowledged that the physician was important to the patient. As a Tenuate ad made clear, the goal was set by the physician and the patient. All the drug could do was to “aid” in it being reached.86 Nevertheless, many advertisements made reaching the goal seem relatively painless. An Iodobesin ad of a sleeping overweight man dreaming of a “trophy” body assured its physician-readers that prescribing the drug (a mixture of glandular extracts) was “simple, convenient, effective” with “no drastic diets.”87 Without the drug “aid,” the physician would have to face out-of-­ control patients, often represented through food temptation. An ad for Biphetamine used a photo of an obese man dressed in a good suit, having a meal in a restaurant and being offered a choice of desserts by an attractive and slender waitress. The image provides little sense that the man can resist temptation, and the conclusion is that he will need help.88 Of course the temptation is two pronged – the dessert and the lovely waitress – and the ad obliquely appealed to the humorous trope of opposites. A Ponderal ad included a drawing of a huge sandwich, piled high and cinched together with a belt. The message – this is what fat people are.89 The message was clear without a person being the ­focus of the visual. Being out of control was equated with failure. A Tenuate Dospan ad referred to the “weight loss D R O P O U T .” In it is a photo of a chubby woman, wearing shorts and a sleeveless shirt and sitting at a coffee table in her home, an exercise bicycle in the background, reading a magazine rather than exercising. She represented the patient whom any doctor would know “well”; she had tried everything but could not stick with anything. The ad talked directly to the doctor – “you know she must lose

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weight.” She needed his “help,” his “counsel,” and perhaps an appetite suppressant to get her started on her diet. The advertisement emphasized the problems that overweight patients posed for their doctors. That it depicts a woman accentuated the neediness of the patient.90 Behind the doctor–patient relationship was, from the patient’s perspective, an unseen player. That player, the pharmaceutical company, had gone into a partnership with practitioners. In the medical historiography, patient agency (or lack thereof) looms large. The literature on popular magazines and advertisements has pointed out the agency of readers to reject the message or not or to reinterpret it.91 That is true of physicians and reactions to the medical advertisements in the medical journals. At the same time, we should not underestimate the power of the ads. As Tomes concluded about the American situation, “The most heavily advertised drugs are those most prescribed by physicians.”92 But agency is one of those terms that is too often written as an absolute. It is not. The concept has limitations and restrictions in its application. The agency of patients in the advertisements was two-fold – to make the decision to seek medical treatment and to follow the doctor’s instructions. The latter was not always easy, but the drugs as advertised were the crutch on which patients were to depend until they were able to control their appetite and eating. The agency of the physician was to read the advertisements, believe them, choose the best product for the patient, and monitor the patient. If the patient did not lose weight or did not keep the weight off, the blame fell on the patient, not the physician; that is, the patient had the agency to fail, a concept that in recent years many critics of the “obesity epidemic” have challenged.93 Agency, then, can be liberating or limiting, constructive or destructive. Indeed, much of the non-medical challenge to the “obesity epidemic” is based on a critique of what is called “healthism,” which indicates that it is the responsibility of the individual to maintain health, not that of society or government to maintain an environment to support health.94

Conclusion Advertisements for obesity drugs are a significant historical source. They are predicated on the power of medicine and the willingness of its practitioners to prescribe drugs. But that power has meaning only if drugs are available, if physicians judge them useful, and if the wider population believes in their efficacy. All three conditions came together in the post-war years and beyond. The number of ifs in the process of

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marketing these drugs, however, suggests the contingent nature of medical success. The medical profession is enhanced by societal belief in its power, and that belief has been extended to include the work done by pharmaceutical companies. Advertisements of the period under study reveal the increasing role played by pharmaceuticals within medical practice and also the increasing importance of the industry’s support of the journals in which its products appeared. They were a reminder to physicians of what the point men for the various companies had already told them about certain drugs or would later confirm. The text of the advertisements, the part that “pushed” a specific pharmaceutical, became a comfort zone through the expression of shared values. It directly engaged the practitioner in a dialogue and suggested a partnership being forged. Much of the dialogue was one sided and didactic, however, providing physicians with information about a drug’s safety and efficacy to encourage its use. Ads thus became part of a medical practice, informing and educating physicians. The impact of advertisements was heightened by cartoons, drawings, and photographs. In them, the characterization of gender comforted the reader in its familiarity: the differences between men and women depicted in their dress, location, and activities; the separation of potential patients into sedentary and active eaters, and into those for whom obesity lessened their attractiveness and those for whom it threatened their health in a specific, class-identified way. Since most practitioners of the time were men, the depiction of gender was intended to appeal to them. As the number of women physicians increased, ads adjusted to the new readership. Idealized female nude drawings, for example, do not appear beyond the 1950s. Relatively stable over the years was the depiction of obese and overweight men and women as respectable, white, middle-class, middle-aged individuals who were owed respect and assistance. They were in need of medical help. Only in the cartoons were there suggestions of the perceived outsider role played by those who were fat. But underlying that commonality, whether of respect or not, was a gendered perception of why a particular patient needed help and of what that help should consist.

Acknowledgments This essay is part of a larger project on the history of obesity in Canada, 1920–80, supported by the Canada Research Chair program and the

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Canadian Institutes of Health Research. Thanks to my research assistants, Carol Cooper, Cheryl Dietrich, Nicole Fera, and Sarah Morse.

notes  1 Dexedrine ad, c m a j 89, no. 2 (13 July 1963): 33.   2  For a detailed listing on the history of medical education see Roland and Bernier, Secondary Sources in the History of Canadian Medicine. Most of the literature listed examines the formal education of doctors. For non-Canadian material see Bonner, Becoming a Physician; Kaufman, American Medical Education; Ludmerer, Time to Heal; Rothstein, American Medical Schools and the Practice of Medicine; Numbers, The Education of American Physicians. Kenneth Clute, in his The General Practitioner, is one of the few who addresses many of these informal pathways. For the relationship between medicine and pharmaceutical companies and their detail men see Clarke, Health, Illness, and Medicine in Canada, 376–97; Crabb, “Minor Tranquilizing Drugs,” 204. For education and pharmaceutical companies see an excellent analysis by Greene, “Keeping Modern in Medicine,” and for detail men see his “Attention to ‘Details.’” The best work on this for the Canadian context is Millar, “The Pharmaceutical Industry’s Influence.”  3 The c m a j is the journal of the Canadian Medical Association, and Canadian Doctor is a business journal for the profession. For more on the c m a j and the role played by advertisements in financing it, its subscription, and readership see Molyneaux, “In Sickness and in Health,” 17–18, 23–6; Lexchin, The Real Pushers.  4 Dummitt, The Manly Modern Masculinity in Postwar Canada; Gardner, Risk.   5  Lloyd Percival “Our Flabby Muscles are a National Disgrace,” Maclean’s 66, 8 (15 April 15 1953): 20–1, 71–3; E.W. Bannister, S.R. Brown, H.R. Loewen, and H.C. Noran, “The Royal Canadian Air Force 5BX Program: A Metabolic Evaluation,” Medical Services Journal, Canada (23 November 1967): 1237–44; on ParticipA C T I O N see Edwards, “No Country Mouse,” S6–S13.  6 Dexedrine ad, c m a j 86 (24 February 1962): 21.   7  See Rose and Novas, “Biological Citizenship,” 439–63. Biological citizenship can be seen in the perception of the higher percentage of women ­being fat. In studies of the time seldom was the role of fat considered in the sexes. As some modern-day critics of the obesity panic have suggested, fat in women is linked to femaleness and the ability to conceive, to breastfeed, and to appear sexually attractive to men. See Hartley, “Letting Ourselves Go,” 67–8; Oliver, Fat Politics, 83.

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  8  On drugs see Leona Crabb, “Minor Tranquilizing Drugs and the Medical­ ization of Everyday Life in Canada;” Clow, “An Illness of Nine Months’ ­Duration,” 45–66; Lexchin, The Real Pushers; Cartwright, Forces of Habit; DeGrandpre, The Cult of Pharmacology; Grinspoon and Hedblom, Speed Culture; Healy, The Anti-Depressant Era; Herzberg, Happy Pills; Jenkins, Synthetic Panics; Rasmussen, On Speed; Tone, The Age of Anxiety; Tobbell, Pills, Power and Policy; Tone and Watkins, Medicating Modern America.  9 Bliss, The Discovery of Insulin. 10  Tomes, “Merchants of Health,” 525. 11  For varying rates see E.W. McHenry, Ruth Crawford, and Lillian Barber, “The Heights and Weights of a Canadian Group,” Canadian Public Health Journal 38, no. 9 (September 1947): 437–41 (sixteen per cent); J.A.F. Stevenson, “Trends in Nutrition,” Canadian Services Medical Journal 12 (April 1956): 354 (eighteen per cent of men and fifteen per cent of women); Ostry, Nutrition Policy in Canada, 6 (thirty-three per cent). 12  A.H. McFarlane and Brian P. O’Connell, “Morbidity in Family Practice,” c m a j 101, 5 (6 September1969): 262; P.M. Crockford and P.A. Salmon, “Hormones and Obesity: Changes in Insulin and Growth Hormone Secretion,” c m a j 103, no. 2 (18 July 1970): 147; Helen Christie, “Obesity is a major topic of papers at annual scientific meeting of O M A ,” c m a j 108, no. 12 (23 June 1973): 1547. 13  Molyneaux, “In Sickness and in Health.” In an excellent gender study of the c m a j advertisements, Molyneaux focuses predominantly on how women were depicted. My interest in the ads is in how the ads described gender (both men and women) and how the advertisements informed physicians about obesity. 14  See Thomas Wendelboe’s chapter in this volume for a description of the use of visual sources. For an overview of print culture and advertising see also Molyneaux, “In Sickness and in Health,” 10–15 and chapter 1, “Advertising the Female Form: Historians and the Visual,” 33–57. For more on advertising see Agres, Emotion in Advertising; Apple, “They Need It Now;” Barnard, “Advertising: The Rhetorical Imperative,” 26–41; Barthel, Putting in Appearance; Johnston, Selling Themselves; Marchand, Advertising the American Dream. On the visual see Belton, Sights of Resistance; Lalvani, Photography, Vision, and the Production of Modern Bodies; Bordo, The Male Body; Helps, “Body, Power, Desire,” 126–50; Leder, The Body in Medical Thought and Practice; Lears, Fables of Abundance; Burke, Eyewitnessing; and for the emotional element of advertisements and how they work to increase the belief in rise see Gardner, Risk, 156.

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15  For use of medical journals see Clute, The General Practitioner, 454. For medical advertisements see Molyneaux, “In Sickness and in Health” and her “Controlling Conception.” 16  Kennedy, “One Hundred Years of Pharmacy Legislation,” 29. 17 Carstairs, Jailed for Possession, 61–2. 18  Robert Emmet Curran, Canada’s Food and Drug Laws (Chicago: Commerce Clearing House, 1953), 131. The United States did not put amphetamines on the prescription list on the second most strict schedule of drugs. Rasmussen, “Goofball Panic,” 44. 19  See Lawrence Galton, “Weight Control,” Canadian Home Journal 54, no. 7 (November 1957): 10 and Lawrence Galton, “New Aid for the Overweight,” Canadian Home Journal 54, no. 12 (April 1958): 12–13. Greene and Herzberg have identified Galton as such a writer. Greene and Herzberg, “Hidden in Plain Sight,” 798. 20 Herzberg, Happy Pills, 4. For focus on the consumer as the patient see Tomes, “Merchants of Health.” The advertisements in the Canadian medical journals did not address themselves to consumers or even patients. 21 Clarke, Health, Illness, and Medicine in Canada, 377, 380. 22  Ibid., 381–7, 393. By the early 1970s, ninety-five per cent of drug patents in Canada were “owned” by individuals / companies with foreign country residence. Millar, “The Pharmaceutical Industry’s Influence,” 21. For ownership see Millar, “The Pharmaceutical Industry’s Influence,” 100. 23  Millar, “The Pharmaceutical Industry’s Influence,” 111, 125; Tone and Watkins, Medicating Modern America, 3. 24  For studies see Dexedrine ad, Canadian Doctor 13, no. 5 (April 1947): 101; Dexedrine ad, Canadian Doctor 13, no. 5 (May 1947): 101. For context see Sanorex (mazindol) ad, Canadian Doctor 41, no. 2 (February 1975): 80–2. The difference in the advertisements was based on a comparison of the Journal of the American Medical Association with the c m a j . 25  Crabb, “Minor Tranquilizing Drugs,” 22–34. For more information on drug legislation see Crabb, “Minor Tranquilizing Drugs,” 141–2, 187–90. Only in 1942 did the federal legislation have a role in approving prescription drugs. Millar, “The Pharmaceutical Industry’s Influence,” 125. 26  Crabb, “Minor Tranquilizing Drugs,” 192. 27  See Lexchin, “Drug Makers and Drug Regulators,” for an overview of pharmaceutical companies and their regulation in Canada, including their advertisements. See also Lexchin, “Canadian Marketing Codes.” 28  On reaction to obesity and pharmacology, see Clute, The General Practitioner, 300, 315, 351, 354. On nutrition see Mrs. Garland Foster, “Hospital Diets,” Canadian Nurse 16, no. 5 (May 1920): 267; Milton A.

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Bridges, “The Physician and Modern Dietetics,” c m a j 34, no. 6 (June 1936): 660; Nan O. Garvock, “Low Cost Special Diets,” Canadian Nurse 39, no. 2 (February 1943): 123; H. Ruth Crawford, “Meal Planning and Preparation,” Canadian Nurse 43, no. 6 (June 1947): 435; Ann Pappert, “Food Bites Back,” Canadian Doctor 39, no. 2 (February 1973): 58; David Woods, “Nutrition for All: Medical Interest Seems to be Awakening,” c m a j 116, no. 5 (5 March 1977): 531. For a major overview of the history of ­nutrition see Ostry, Nutrition Policy in Canada. 29  Podolsky and Greene, “A Historical Perspective of Pharmaceutical Promotion and Physician Education,” 831; see also Lexchin, “Profits First,” 710. 30  Waugh and Bailey, “Medical Education.” 31 Clarke, Health, Illness, and Medicine in Canada, 831. 32  See Gordon and Fowler, The Drug Industry. 33 “Announcement,” Ontario Medical Association Bulletin 2, no. 1 (February 1935): 2. 34  Probese ad, Canadian Doctor 18, no. 12 (December 1952): 16. U S P is the quality and standard determined by the United States Pharmacopeia. 35  Millar, “The Pharmaceutical Industry’s Influence,” 29–30. 36 Clute, The General Practitioner, i, 149, 164. 37 Lexchin, The Real Pushers, 152. 38  Dexedrine ad, Canadian Doctor 14, no. 10 (October 1948): 109. 39  See Clow, “An Illness of Nine Months’ Duration,” 49–54. Thanks to Lisa Rumiel for pointing this out. 40  Dexedrine ad, c m a j 65, no. 2 (August 1951): 173; Dexedrine ad, c m a j 75, no. 7 (1 October 1956): 617. For danger of weight during pregnancy see Molyneaux, “In Sickness and in Health,” 130, 158, 160. 41  Probese ad, c m a j 78, no. 6 (15 March 1958): 70. See also Preludin (phenmetrazine hydrochloride) ad, c m a j 78, no. 2 (16 January 1957): 59; New Tenuate (diethylpropion) ad, Canadian Doctor 26, no. 1 (January 1960): 9. 42  For diabetes and hypertension see ads for Dexedrine in c m a j 75, no. 7 (1 October 1956): 617 and c m a j 73, no. 3 (1 February 1958): 225. For heart problems see New Tenuate ad, c m a j 82, no. 23 (4 June 1960): 38; for heart see Didrex (benzphetamine) ad, c m a j 86, no. 15 (14 April 1962): 18–19. 43  Tenuate ad, c m a j 94, no. 8 (19 February 1966): 41; Ponderal ad, c m a j 107, no. 8 (21 October 1972): 728. 44 Montigny, The Real Dope, 5. See also Carstairs, Jailed for Possession, and Martel, Not This Time.

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45 Ramussen, On Speed, 140. See also concerns about diet pills in Sheila Kieran, “A Frank Report on Some Diet Doctors,” Chatelaine 46, no. 12 (December 1973): 50, 68–71. 46  Dexamyl and Dexedrine ad, c m a j 103, no. 12 (5 December 1970): 1306; for combination of drugs, see Willidrene (methamphetamine secobarbital) ad, c m a j 78, no. 4 (15 February 1958): 67. 47  See, for example, an advertisement for D B I and D B I -T D (phenformin ­hydrochloride) c m a j 90, no. 5 (1 February 1964): 3. 48  Prelutal ad, c m a j 90, no. 11 (14 March 1964): 15. 49  Tobbell, “Who’s Winning the Human Race?” 437. For Canada see Millar, “The Pharmaceutical Industry’s Influence,” 157. In 1975 ads were vetted by the Pharmaceutical Advertising Advisory Board, which had industry representation on it. Millar, “The Pharmaceutical Industry’s Influence,” 182. 50  Probese and Dexobese ad, Canadian Doctor 17, no. 2 (February 1951): 12; Pre-Sate ad, c m a j 93, no. 15 (9 October 1965): 1–9. For use of cats as ­experimental animals see Lindee, “Experimental Wounds.” 51  Desbutal Gradumet (methamphetamine with pentobarbital) ad, c m a j 94, no. 16 (16 April 1966): 30. 52  Biphemetamine and Ionamin ad, c m a j 84, no. 9 (4 March 1961): 13. 53  Adjudets ad, Canadian Doctor 18, no. 4 (April 1952): 26; see also Probese V.M. ad, c m a j 76, no. 8 (15 April 1957): 44. 54 Clarke, Health, Illness, and Medicine in Canada, 389. 55  Dr. Geekie, “Special Report,” c m a j 106, no. 10 (20 May 1972): 1124A. 56  Pre-Sate ad, Canadian Doctor 31, no. 1 (January 1965): 13. 57  Biphetamine, Ionamin, and Biphetamine-T ad, c m a j 92, no. 25 (19 June 1965): 58–9. 58  Biphetamine, Ionamin, and Biphetamine-T ad, c m a j 93, no. 18 (30 October 1965): 17. 59  Pre-Sate ad, Canadian Doctor 39, no. 9 (September 1973): 82–3. See also Dexedrine and Dexamyl ad, c m a j 103, no. 12 (5 December 1970): 1306– 7; Ponderal ad, c m a j 107, no. 8 (21 October 1972): 728; Tenuate ad, c m a j 112, no. 4 (22 February 1975): 498; Tenuate Dospan ad, c m a j 105, no. 12 (18 December 1971): 1294. 60 Herzberg, Happy Pills, 73. 61 Rasmussen, On Speed, 155, 238. 62  Pre-Sate ad, c m a j 95, no. 12 (17 September 1966): 17–20. 63  While Monyneaux suggests the “numerical representation of women” is not significant but rather how they are portrayed, she does emphasize the dominance of women in the pharmaceutical ads. Molyneaux, “In Sickness

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and in Health,” 15. See also Crabb, “Minor Tranquilizing Drugs,” 201, for a similar gender analysis of ads for mebrobate in which women were depicted in thirty per cent of the ads and men in only twenty per cent. 64  Probese ad, Canadian Doctor 13, no. 4 (April 1947): 101; Dexedrine ads, c m a j 76, no. 6 (15 March 1957): 519 and c m a j 77, no. 2 (15 July 1957): 171. 65  For more on the monstrous see Clear, “The ‘Normal’ and the Monstrous in Disability Research,” and Braidotti, “Mothers, Monsters, and Machines.” 66  Dexedrine ad depicting the man, c m a j 68, no. 1 (January 1953): 91; Ionamin ad of cartoon man, c m a j 89, no. 2 (13 July 1963): 30; Dexedrine ad depicting the woman, c m a j 69, no. 4 (October 1953): 463; for home setting see also Dexamyl ad, c m a j 88, no. 7 (16 February 1963): 26. See Herzberg, Happy Pills, 62–82, for discussion of gender in medical advertisements for anti-depressants. 67  Dexedrine ad, c m a j 72, no. 10 (15 March 1955): 479. 68  D.E. Rodger, J. Grant McFetridge, and Eileen Price, “The Management of Obesity,” c m a j 63, no. 3 (September 1950): 268. 69  Desbutal Gradumet ad, c m a j 87, no. 8 (25 August 1962): 16. 70  Biphetamine-T ad, c m a j 94, no. 16 (16 April 1966): 23. 71  A study using dependency is Doris L. Hirsch and W.I. Morse, “Emotional and Metabolic Factors in Obesity,” Canadian Journal of Public Health 51, no. 11 (November 1960): 450–3, 455. 72 Rasmussen, On Speed, 135. 73  Preludin ad, c m a j 80, no. 10 (1 May 1959): 75. 74  McPhail, “Canada Weighs In,” 166. The focus on men’s health and not them feeling “needy” was also apparent in the ads for minor tranquilizers. Crabb, “Minor Tranquilizing Drugs,” 277. 75  Probese ad, Canadian Doctor 22, no. 3 (March 1956): 73; Ionamin ad, c m a j 97, no. 9 (26 August 1967): 21. 76  L. Bradley Pett, “Public Health, Ottawa Newsletter … Appetite Control in Obesity,” c m a j 76, no. 12 (15 June 1957): 1083. 77  Ionamin ad, c m a j 88, no. 26 (29 June 1963): 24. For a similar connection between being effeminate and overweight in young boys see Greig, “The Idea of Boyhood in Postwar Ontario,” 119–21. For trampoline man see Biphetamine ad, c m a j 89, no. 6 (10 August 1963): 22. 78  Ionamin ad, c m a j 89, no. 9 (31 August 1963): 20. Certainly making fun of fat women could be found on humour pages, even in medical journals. 79  Probese ad, Canadian Doctor 16, no. 5 (May 1950): 29. 80  Dexedrine ad, c m a j 90, no. 12 (21 March 1964): 25. 81  Biphetamine ad, c m a j 94, no. 21 (21 May 1966): 28.

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82  Probese ad, Canadian Doctor 15, no. 12 (December 1949): 77. See Probese and Dexobese ads in Canadian Doctor 17, no. 10 (October 1951): 20; Canadian Doctor 18, no. 10 (October 1952): 76; Canadian Doctor 19, no. 1 (January 1953): 59; Canadian Doctor 20, no. 1 (January 1954): 67. Ionamin ad, c m a j 94, no. 15 (19 April 1966): 14. 83  Dexedrine ad, c m a j 76, no. 10 (15 May 1957): 915. 84  Probese ad, c m a j 76, no. 8 (15 April 1957): 44. 85 Lexchin, The Real Pushers, 103–5,120–8; Restrictive Trade Practices Com­ mission, Report Concerning the Manufacture, Distribution and Sale of Drugs (Ottawa: Queen’s Printer, 1963), 220, 273; Crabb, “Minor Tranquilizing Drugs,” 203. 86  Tenuate ad, c m a j 105, no. 12 (18 December 1971): 1294. 87  Iodobesin ad, Canadian Doctor 14, no. 3 (March 1948): 54. 88  Biphetamine ad, c m a j 96, no. 22 (3 June 1967): 28. 89  Ponderal ad, c m a j 107, no. 8 (21 October 1972): 728. 90  Tenuate Dospan ad, c m a j 105, no. 12 (18 December 1971): 1294. 91  See Korinek, Roughing it in the Suburbs. 92  Tomes, “The Great American Medicine Show Revisited,” 631. 93  For literature on fat rights and activism see Braziel and LeBesco, Bodies Out of Bounds – in this book none of the authors address the health issues of obesity; for health issues see Schlesinger, “Weighting for Godot,” editor’s note, 787; Saguy and Riley, “Weighing Both Sides,” 882; Cahnman, “The Stigma of Obesity,” 285; LeBesco, Revolting Bodies. 94  See Crawford, “Healthism and the Medicalization of Everyday Life” and Cheek, “Healthism.”

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12 Motherhood Gone Mad? The Rise of Postpartum Depression in the United States during the 1980s Rebecca Godderis On a September afternoon in 1983, Jeff Thompson arrived at his home in Sacramento, California, to find that his infant son had been murdered by his wife, Angela. She had placed the baby in a box beside the house, scattered the box with mothballs and covered it with a towel. Angela believed the mothballs were rosary beads, that her nine-month-old son was the devil, and that her husband was Christ, who would raise the baby from the dead within three days to rid the world of evil. Originally charged with first-degree murder, Angela Thompson was acquitted of the crime by reason of temporary insanity. Following her acquittal, Angela and Jeff became involved in a growing grassroots movement that was bringing attention to women’s mental health issues in the postpartum period. This movement was led by two postpartum self-help organizations that had developed in the United States during the early 1980s: Depression After Delivery (D A D ) and Postpartum Support International (P S I ). Angela and Jeff, along with members of these advocacy groups, participated in hundreds of media interviews about infanticide during this decade.1 The public was fascinated with the topic and, as the media continued to print headlines about “killer moms,” mothers began contacting D A D and P S I in record numbers.2 Discussions about infanticide inevitably led to highly medicalized explanations of women’s postpartum distress. This extreme and violent act was thought to be caused by delusions and hallucinations that occurred when a woman experienced postpartum psychosis, a temporary

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state that is often described as an “individual losing touch with reality.”3 However, diagnosed psychotic episodes in the postpartum period were, and continue to be, incredibly rare events, and the possibility that such an experience may lead to violence was even more unusual. Only one to two women per 1,000 births are diagnosed as having had a psychotic episode, and few of these women experience the delusions or hallucinations that may lead to infanticide.4 Given that psychosis was an uncommon experience, postpartum self-help advocacy groups like D AD and P S I were more troubled by what they understood as a general lack of support for new mothers. Thus, although these groups often relied on the media stories of infanticide and psychosis to draw attention to the issues of the postpartum period, the objectives of the postpartum self-help movement were to support every woman who had recently given birth, not just those who had been diagnosed with a postpartum mental illness.5 However, despite the initial desire of the members of the postpartum support movement to assist all new mothers, as the groups developed during the 1980s they became closely aligned with psychiatrists. By the end of the decade leaders of the postpartum advocacy movement had, almost exclusively, adopted the language of postpartum mental health problems to further their cause, and they specifically focused on postpartum depression (P P D ) as a central issue.6 This signalled an interesting shift from being concerned more broadly with the transition to parenthood toward a medicalized version of “the problem.” In sociologist Verta Taylor’s history of the P P D self-help movement, it is noted that postpartum activists were often critiqued by feminist organizations as relying too heavily on these medicalized definitions of women’s experiences while downplaying gender-based social, political, and economic inequities that made mothering difficult in American society. Taylor argues that such feminist characterizations of the postpartum support movement ignored how the self-help groups remained committed to original feminist ideals while also transforming feminism by adopting new techniques such as strategic alliances with medical professionals.7 Thus, Taylor ends up challenging the feminist critique by emphasizing the role of women in the process of medicalization and highlighting women’s agency.8 Taylor’s analysis of the movement is thorough but overlooks an intriguing aspect of the history of P P D : that the concept of P P D was not only newly adopted by the postpartum support movement but, in fact, was relatively new to the discipline of psychiatry itself. While medical

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texts from the nineteenth and early twentieth centuries document some cases of severe, and occasionally violent, temporary postpartum reactions (similar to what now may be labelled as postpartum psychosis), discussions about milder forms of longer lasting distress that mothers may face after childbirth were largely absent from medical discourse. Health practitioners understood gloomy and low moods as common among postpartum women, which meant that mild depression was viewed as normal and not in need of medical attention.9 The 1950s marked a change in psychiatric thinking. During this period, a limited number of research studies investigated what had been categorized as symptoms of depression occurring in the postpartum period; however, this research gained limited attention within psychiatry and the medical community more broadly. It actually was not until the 1980s that the amount of psychiatric research on P P D grew at an extraordinary rate, and postpartum mental health issues began to receive publicity in the news and on daytime T V talk shows across North America.10 The lack of interest in forms of depression during the postpartum period until well into the 1980s is particularly remarkable given shifts that had occurred in American psychiatry directly following the Second World War. During the post-war era until the mid-1970s psychodynamic psychiatry was the primary framework adopted by American psychiatrists. The acceptance of the psychodynamic model had two important implications. The first was an increasing concern with mild conditions, such as neuroses and depression, which led to a broadening of what illnesses psychiatrists could legitimately treat. According to psychodynamic psychiatrists, minor problems were important to address because these seemingly inconsequential issues could lead to more severe distress, but also because the resolution of minor problems was, in and of itself, a worthy goal. The second implication was that this expansion of who and what could be treated meant that psychiatry shifted away from an asylum-based psychiatric system, which only treated severely ill individuals who were housed in institutions, and moved toward practising psychiatry in the community.11 It seems that this increasing interest in milder forms of psychiatric illness would be likely to translate into research on P P D during the 1950s and into the 1960s. Yet, as I will show in this chapter, P P D did not garner much attention from the psychiatric community until well into the 1980s. Building on feminist and Foucauldian theory, I use a critical historical framework to explore the increasing attention paid to P P D during the 1980s. I adopt a constructionist stance that calls attention to the impact

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of broader socio-political contexts on the development of scientific and medical knowledge on the basis of a close reading of P P D -related psychiatric research literature from the mid-1950s to 2007. This information was supplemented by two in-depth interviews with Jane Honikman, founder of P S I , and a number of secondary sources about P P D , psychiatry, and the political context of the United States during the 1980s. The analytic goal of this work is to demonstrate how psychiatric and public understandings of P P D have been influenced by social, political, and economic circumstances.12 This reading of the history of P P D develops a more nuanced understanding of the socio-political conditions that encouraged an increasing interest in the illness during the 1980s. It is clear from Taylor’s account of the P P D self-help movement that, during the 1980s, women played a significant role in adopting psychiatric explanations of women’s distress and used this framework as the basis for collective action that demanded that the medical community take the concerns of postpartum women seriously by paying more attention to the issue of P P D . But it is also clear from the psychiatric literature that, at the same time, there was a sudden increase in the amount of P P D -related psychiatric research being produced. I argue that the simultaneous advancement of psychiatric research along with the development of self-help advocacy groups ­indicates a broader social shift that encouraged an interest in issues related to mothering and the family, with a particular focus on the bodies of women. More specifically, I argue that concern over P P D was consistent with the right-wing “pro-family” political agenda, a growing movement that generated broad social concern in the United States about the breakdown of the traditional nuclear family. Within the socio-political context of a conservative policy agenda, the ideology of healthism and the neoliberal governance of health and health care were continuing to gain significant ground. These approaches to health emphasized the responsibility of the individual to become a healthy citizen. As a result, psychiatric explanations of postpartum distress that emphasized the potential harm of P P D to children and families, while also locating the cause of that harm in individual women, were particularly well suited to the social and political context of the United States in the 1980s. By the mid-1980s psychiatrists and self-help groups had become closely aligned, further supporting the notion that the psychiatrically produced language and discourse of P P D , which located the problem in individ­ ual bodies rather than structural gender inequities (such as the lack of

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accessible daycare), were particularly effective in supporting claims about the need for increased assistance to women. In highlighting this specific context, I am not assuming that the increasing interest in P P D was part of a right-wing campaign to keep women in traditional gender roles. That particular argument overlooks the complex and contradictory nature of the regulation of health in a neoliberal society, especially since it was often women themselves who were legitimately concerned about their children and who expressed anxiety about the state of the family in contemporary American society. Instead of focusing on such questions of motive or intent, the analysis presented in this chapter attempts to identify the discursive conditions of a specific historical period that made P P D the most acceptable account of women’s postpartum distress. This work illuminates a number of key themes explored in this volume, including how the causes of ill health have become highly individualized, while drawing awareness to how such individualized explanations of health and illness are in fact tied to  socially prescribed gender norms and gendered notions of health that are directly linked to historically specific ideals of health, family, and citizenship.

Postpartum Depression as a N e w P s yc h i at r i c C o n c e p t During the nineteenth century and the first half of the twentieth there was little discussion in the psychiatric research literature of the illness that has come to be known as P P D . Throughout this time the medical community largely focused on a condition that was termed puerperal insanity. Most similar to the present-day concept of postpartum psychosis or manic depression, puerperal insanity described a woman who had “relatively brief attacks, nervous upsets, violence or delusions, as well as long-term manifestations of mania or deep and protracted melancholia, which could put at risk the life of the mother and child.”13 In comparison, low moods and depression were thought to be a normal reaction for women in the postpartum period and thus were not defined as illness. Starting in the 1950s empirical research on milder forms of postpartum mental illness began to appear in the major psy­ chiatric journals. One of the first such articles was R.E. Hemphill’s “Incidence and Nature of Puerperal Psychiatric Illness,” published in 1952. Hemphill examined 37,000 case records of women who delivered at maternity hospitals in Bristol, England, hoping to establish whether

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psychiatric illness during pregnancy and postpartum could be considered a “specific clinical entity” that was directly related to childbirth.14 Hemphill included the categories of depression, neurosis, and “confusion and exhaustion,” in addition to the more standard categories of psychosis and schizophrenia, to capture a range of experiences, and this was one of the first studies to document depressive symptoms in the postpartum period. What was particularly interesting about Hemphill’s work was his conclusion that depression was, in fact, a serious and significant issue for postpartum women – a novel argument in the research literature at the time.15 Later in the 1950s, psychiatrists Richard and Katherine Gordon also began to include milder forms of distress in their research on the postpartum period. Specifically, the Gordons argued for the use of more inclusive terms (such as “maternity syndrome”) to describe psychiatric illnesses that occurred after childbirth, to recognize the impact of depression and anxiety in addition to more severe conditions.16 They stressed that the often-exclusive focus on temporary, atypical, and potentially dangerous states like psychosis was to the detriment of women because other emotional disorders were frequently ignored.17 A third contributor to this growing interest in milder forms of ­postpartum mental illness was James Hamilton. Hamilton published Postpartum Psychiatric Problems in 1962, a book in which he introduced his theory that there existed a spectrum of postpartum mental illnesses, which included, but was not limited to, postpartum psychosis. Other postpartum illnesses included an “affective syndrome” in which a woman would fluctuate between high (manic) and low (depressive) moods, and a “transitory syndrome,” now commonly referred to as the baby blues, whereby a woman experienced a temporary but significant depression three to five days after childbirth.18 Hemphill’s 1952 article, the Gordons’ work in the late 1950s and early 1960s, and Hamilton’s Postpartum Psychiatric Problems in 1962 are empirical examples of the increasing interest in milder forms of postpartum psychiatric distress in women among a few psychiatrists midway through the twentieth century. However, despite the pleas of these individuals that researchers produce more data so that better evidence would exist to inform psychiatric understandings of the causes and treatment of P P D ,19 few studies were conducted and little progress was made in the field for the next twenty years. James Hamilton is quoted as saying that this lack of recognition led to the “barbaric treatment of postpartum patients” by the medical community for decades.20

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Then, beginning in the 1980s, a radical shift occurred. From approximately 1980 to 1990, well over 100 studies were published focusing solely on depression in the postpartum period.21 During this time a number of psychiatrists also began to establish research careers focused exclusively on the study of P P D , an indication that interest in the illness was sufficient for researchers to rely on funding from government and other agencies to provide support for their work.22 The phenomenal growth in P P D research over such a short period was surprising given that previous calls to action went unheeded. Moreover, P P D had yet to  be added to the Diagnostic and Statistical Manual of Mental Disorders (d s m ), the document published by the American Psychiatric Association that lists all officially recognized mental disorders and their symptoms. In fact, depression with postpartum onset, the first version of P P D to be added to the d s m , would not be included until 1994.23 What was occurring in the United States during the 1980s that sparked such ­interest in P P D ?

Postpartum Depression and t h e “ P r o - F a m i ly ” A g e n da Motherhood is intimately connected to a woman’s cultural status and identity. What it means to be a mother in Western society also speaks to the roles and identities appropriate for women in a given society. In Western nations, it is commonly assumed that pregnancy, childbirth, and mothering are unequivocally positive events in a woman’s life and that mothering is a natural role for women. Hence, the “good mother” is not supposed to find mothering to be a challenge or a burden.24 Given this maternal ideal, the experience of distress during the postpartum period embodies the most extreme contradiction of assumed natural gender roles: the woman who suffers because of motherhood. Feminist scholars have been concerned that rather than seeing difficulty, struggle, and anger as normal aspects of the transition to parenthood, psychiatric conceptions of P P D carry with them an assumption of the maternal ideal that reinforces the “irrefutable beliefs about women’s ‘nature,’ capabilities, and behavior … imply[ing] that women adapt to the role of  mother without protest, exhibiting positive emotional reactions, with little disturbance to their own lives and those of their close companions.”25 Moreover, as pointed out by many feminist scholars, this idealized version of motherhood is a Westernized concept rooted in problematic assumptions about class, race, ability, and sexuality.26

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Medicalized versions of the maternal ideal, expressed through the psychiatric concept of P P D , map onto political claims about appropriate gender roles. During the 1980s, the new right political movement in the United States – particularly the new religious right – supported state enforcement of “moral gender relations”. These relations were most clearly symbolized by the traditional nuclear family that relies heavily on the maternal ideal.27 For example, conservative political activists such as Phyllis Schlafly, vice-president of the National Federation of Republican Women, argued that the defence of morals and traditional values was required for a well-ordered American society.28 Thus, the well-being of the nation depended on the maintenance of moral order, which in turn depended on the Christian-defined nuclear family unit in which women were homemakers and men were breadwinners. Schlafly felt that a key role of the government was to protect this nuclear family unit and, as such, she was one of the most outspoken opponents of the Equal Rights Amendment (E R A ). The E R A proposed sweeping amendments to the American constitution to prevent discrimination on the basis of sex and was designed to guarantee equal rights for women in the United States. Schlafly vehemently opposed the E R A and mobilized conservatives to vote against the amendment, because she believed this legislation would eliminate the appropriate divisions between male and female labour in American society, thereby undermining women’s ability to fulfil their proper, natural, God-given role in the domestic sphere as mother and as caretaker of her husband.29 In her history of right-wing movements and political power in the United States, Sara Diamond comments that the politics of the family resonated “at the most personal, even visceral, level of gender relations.”30 As noted by Barbara Brookes (chapter 7 in this volume), historically specific ideals about “the proper family” have had significant negative impacts on the lives of those who do not fit into such prescribed norms. Similarly, during the 1980s, scrutiny of women who did not follow the established motherhood script was intense, evidenced most dramatically in media coverage of the supposedly increasing numbers of “unwilling mothers” and “maternal delinquents” who were addicted to crack cocaine while pregnant and were thus assumed to have subjected an entire generation of babies to permanent, catastrophic brain damage.31 Thus, social anxieties about the breakdown of the traditional family unit were embodied by women through assumptions about women’s willingness to mother and their ability (or inability) to be good, moral mothers. It is within this context of increasing surveillance of

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mothering that media and academic representations of P P D positioned the illness as a threat to family security and stability and therefore as a risk to the very fabric of society. For its part, the media regularly highlighted sensational cases of ­infanticide, emphasizing the dramatic shift when the “loving mother,” understood as the ultimate symbol of protection, becomes the definitive symbol of evil: the mother who kills her own child. Although most ­women who committed infanticide were diagnosed with postpartum psychosis, media stories of such incidents often confused psychosis with depression, claiming that infanticidal mothers were suffering from P P D .32 Thus, despite the clear distinction made in the psychiatric lit­ erature between P P D and postpartum psychosis, the differences were erased in the media’s retelling of these events. Media stories about infanticide also commonly relied on interviews with members of the P P D self-help movement, which further served to blur the distinctions between psychosis and P P D . Because activists were interested in a broad array of women’s postpartum problems, ranging from minor adjustment difficulties to severe psychotic reactions, they would discuss a variety of conditions when being interviewed about infanticide cases. However, this had the unintended effect of (1) obscuring the differences between depression and psychosis, and (2) drawing connections between infanticide and all types of postpartum distress. For example, activists used P P D prevalence statistics to support the argument that it was important to pay attention to all postpartum experiences, and not just cases of psychosis.33 Yet, prevalence numbers for depression and psychosis related to childbirth were dramatically different: the former was as high as twenty per cent and the latter just 0.1 per cent.34 Despite the intention to increase support for all new mothers regardless of illness status, the mention of P P D prevalence rates as high as twenty per cent in the context of infanticide created a sense of panic about the potential number of depressed women who could become “killer moms,” producing a narrative script that linked P P D to the most extreme form of deviant mothering.

Neoliberal Governance and the Rise of Postpartum Depression During the 1980s the neoliberal view that health was an individual responsibility, rather than a liability of the government, was continuing to gain significant ground.35 In terms of the governance of health and

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health care, neoliberal ideologies of health, commonly referred to as healthism, presented strategies through which human behaviour could be surveyed, managed, and regulated. A central element of this strategy was to make individuals responsible for the management of health risks. For example, Wendy Mitchison’s work on obesity (chapter 11 in this volume) points to the ways that citizens were expected to take on the moral responsibility of maintaining their health and preventing illness to contribute to the well-being of the nation by managing the size of their bodies. Individual responsibility has been identified in the governance literature as a significant shift away from an overarching discourse of state-supported health, in which government was understood to have a role in creating a healthy national community, and toward a “politics of the self” in which self-discipline was central to the management of populations.36 Thus, individuals are encouraged to effectively monitor their own bodies and behaviours to become healthy citizens.37 Such neoliberal conceptions of health can be seen in the psychiatrically produced P P D discourse, primarily in the causal theories of P P D that emphasized individual-level variables that could only be addressed by women themselves. Consequently, within the discourse of P P D , which was buttressed by the pro-family agenda, women were identified as a primary threat to children and families and, since the danger came from the individual mother she was also expected to manage and control these potential problems. This positioning of mothers “mobilizes discourses that enlist the cooperation of ‘responsible’ mothers”38 where “responsible motherhood” is narrowly defined as the duty of the mother to monitor her emotions and, if necessary, submit herself to psychiatric treatment. This emphasis on the individual woman as being responsible for monitoring and regulating her own health, as well as the health of her family, is a common theme in this volume and can be seen in the work of Anika Stafford and Mona Gleason on gender non-conforming children (chapter 9), and in Barbara Brookes’ insights regarding the relationship between mothers and their disabled children in mid-­ twentieth-century New Zealand (chapter 7). This responsibilization of women can be illustrated through an examination of P P D -related psychiatric research literature published during the 1980s. Causal Explanations for Postpartum Depression In the 1980s, researchers studying P P D had yet to agree on a specific mechanism that caused the illness.39 While the validity of competing

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hypotheses continued to be debated in the literature, the theories had one thing in common: an exclusive focus on individual-level variables. Causal theories of P P D from the time can be broadly organized into three categories: biological, psychological, and psychosocial. Biological theories examined the effect of hormones (progesterone and estrogen levels) and the role of neurotransmitters (serotonin levels) following childbirth.40 By focusing on physiological determinants of P P D , biologically based causal explanations unambiguously placed the source of distress in an individual woman’s body, arguing that the best form of prevention and treatment was hormone therapy or antidepressants. Thus, to mitigate the danger she might pose to her children, and therefore the family unit, a woman experiencing symptoms of the illness was to submit her body to pharmaceutical intervention. Psychological theories of P P D focused on a woman’s personal vulnerabilities to psychiatric problems and involved examining a number of “personality variables,” such as ability to cope with the role of motherhood, attitude toward pregnancy and mothering, and anxious or negative attitudes toward life more generally.41 Each of these reasons for distress firmly situated the source of the problem within the individual woman’s mind, requiring her to change her patterns of thinking and acting to prevent or treat the illness. Often it was recommended that women seek therapy or attend support groups to help change their ­attitudes and develop their mothering skills.42 Finally, psychosocial theories of causation examined a woman’s relationships with other people and her life circumstances more broadly. Examples of psychosocial factors included lack of social support, marital problems, conflict with mother, obstetrical complications, or recent financial difficulties.43 Even though on the surface these variables may appear less individualized and more social in nature, when operationalized in the psychiatric literature they again exemplify a focus on issues in a woman’s life, thereby reinforcing the need for the individual woman to change her personal circumstances to protect her children and family, rather than rely on changes to federal family policies like those related to maternity leave. For example, four literature reviews published during the 1980s all emphasized a strong correlation between marital conflict and P P D .44 In this literature the level of marital conflict was defined by the number of fights a husband and wife had. As a result of this finding, researchers concluded that reducing the number of fights was a key site for prevention. This narrow definition of marital conflict emphasized the need for the couple to resolve issues that were

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always positioned as being caused by the individuals themselves. What this definition does not identify is how larger social issues, such as gender role expectations and inequitable gender relations, can significantly contribute to martial conflict. Author Anne Kingston has observed that “wifehood” continues to be enmeshed in complicated ways with the perception of women and the female identity in contemporary North American society: “The role of wife has always defined women in a way that husband does not define a man. It is a full-time job encompassing homemaker, hostess, cheerleader, mother, chauffeur, Jill-of-all-trades.”45 As Kingston identifies, the very concept of wife was (and continues to be) instilled with various expectations, yet many of these are left unnamed and unrecognized in American culture. Therefore the work done by women to fulfil such expectations was (and is) often invisible. This point was highlighted in Ann Oakley’s classic study on the sociology of housework, in which she argued that understanding housework as merely a natural aspect of the feminine role disregarded this labour as work, which in turn devalued the effort involved and naturalized domestic duties as simply “what women do.”46 A failure to recognize the labour of women in their roles as wives and mothers meant that institutional structures that could have supported their work, such as affordable and accessible daycare, were not prioritized or understood as possible interventions that could ameliorate marital conflict. Thus, although individual women experienced the roles of “wife” and “mother,” those experiences were (and continue to be) highly social as well – an issue that was completely unaccounted for in psychiatric explanations of P P D . Instead, psychiatric theories located the cause of P P D in the individual woman and reinforced the idea that the responsibility for mitigating risks associated with the illness should fall exclusively on mothers. This process of regulation was not crude or explicitly punitive, but rather enlisted women as allies to ensure the health of their children and families by asking each individual woman to monitor herself for potential signs and symptoms of PPD. Although the involvement of women in the preservation of their own health was not necessarily negative, it is important to examine the gendered nature of this form of health governance. In particular, the significant role of men as partners and fathers was entirely excluded from psychiatric discussions of postpartum problems. Thus, the discursive framing of PPD reinforced traditional gender roles by naturalizing gender differences in relation to childcare and parenting and serving to individualize the problem as only a woman’s issue.

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It is important to note that men’s bodies are not completely ignored by the health-care system. The work by Antje Kampf on male bodies and infertility (chapter 6 in this volume) demonstrates how men’s bodies are also governed by health-care discourses; however, the comparison between these two analyses highlights the different ways that women’s and men’s reproductive bodies are acted upon within the system and thus underscores the gendered nature of health discourses. In the case of P P D it was mothers, and mothers only, who were understood as ­being able to identify and remedy the “problem of P P D .” This effectively erased the social, political, and economic context within which parenting occurred.

Conclusion Using a feminist-inspired Foucauldian framework I have linked the developing interest in P P D in the 1980s to a broader socio-political shift toward conservatism and neoliberal notions of governance at a time when public anxiety about the breakdown of the family was escalating and the conduct of women as mothers was under increasing scrutiny. The new religious right argued that the traditional nuclear family that relied on women’s embodied domestic labour was the foundation of a well-functioning, moral American society. Thus, for a woman to maintain the health and well-being of her children and family was to ensure the health and well-being of the nation. Within a context where women were expected to take on the responsibility of ensuring the health of individuals, as healthism would dictate, but also the health of the nation state through the maintenance of a healthy family, P P D was a significant social problem. P P D symbolized the most extreme contradiction of what were understood to be “natural” gender roles – the woman who suffered because of motherhood. Psychiatric discourse that explained P P D as rooted in the woman’s embodied self provided a solution to the “mothering problem” that ­located the cause of the problem in the individual, thus reinforcing conservative policy agendas that supported versions of the ideology of healthism rather than the examination of social, economic, and political conditions that may have required state-funded policies and programs to address social inequities. In other words, the psychiatric framing of P P D mapped onto forms of neoliberal governance in which individuals were encouraged to see themselves as active participants in the enhancement of their own health and well-being. Self-discipline was

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increasingly seen as key to the regulation of healthy populations, and mothers were mobilized to make what was framed as the only “appropriate” choice to prevent or reduce harm to their children and families: submitting their bodies and minds to individualized psychiatric treatment. Thus, through the discourse of PPD, the responsible and moral postpartum mother became reconstituted and embodied as a psychiatric subject. The current analysis has not explicitly addressed the complex ways that race, class, age, able-bodiness, and sexuality are tied to neoliberal governance through the psychiatrically produced discourse of P P D . Political scientist Lealle Ruhl points out that middle-class, educated women have tended to be the targets of neoliberal interventions related to reproductive health because “it is the very desire of this group to be appropriately responsible liberal subjects that gives the risk model its strength.”47 How the discourse of P P D was used by medical professionals in the 1980s to address different groups of women – and how these women accepted, altered, or resisted a diagnosis of P P D depending on their social location – requires further exploration. To encourage this kind of intersectional analysis, this chapter draws attention to the sociopolitical context within which P P D was understood as a social problem. This emphasis on the social aspects of P P D does not deny women’s ­experiences of distress; however, it does demand a more nuanced understanding of the gendered nature of P P D discourse and questions the idea that individual mothers are responsible for mitigating the risks of P P D without any reference to the social, political, and economic contexts of mothering within contemporary American society.

Acknowledgments I acknowledge the mentorship and analytic insight of Dr Liza McCoy, the encouragement provided by Dr Tarah Brookfield, and the constant support received from the editors of this volume.

notes   1  Jane Honikman (founder of Postpartum Support International), interview by author. Digital tape recording. Santa Barbara, C A , 24 June 2011.  2 Taylor, Rock-a-by Baby, 5–6.   3  It has been estimated that one per cent of postpartum women experience psychosis and that approximately half of these women experience the delusions and / or hallucinations that could (although not inevitably) lead to

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violent behavior. Robert Kendell, “Emotional and Physical Factors in the Genesis of Puerperal Mental Disorders,” Journal of Psychosomatic Research 29, no. 1 (1985): 3.   4  Seyfried and Marcus, “Postpartum Mood Disorders,” 231.   5  Honikman, telephone interview by author. Digital tape recording. Calgary, A B , 13 December 2007.  6 Taylor, Rock-a-by Baby, 4–5.  7 Ibid., 7–8.  8 Ibid., 21.  9 Marland, Dangerous Motherhood, 3–4. 10  Godderis, “Managing Mad Mothers,” 2, 14. 11  Wilson, “D S M -III and the Transformation of American Psychiatry,” 401. 12  The constructionist approach to medical knowledge has been highly developed in the science and technology studies (S T S ) literature. For general reading in S T S see Hackett, et al., Handbook of Science and Technology Studies; Sismondo, An Introduction to Science and Technology Studies. The specific approach to S T S adopted in this chapter is also inspired by feminist scholars, including Fausto-Sterling, Myths of Gender; Harding, The Science Question in Feminism; Haraway, Simians, Cyborgs, and Women. 13 Marland, Dangerous Motherhood, 3. 14  R.E. Hemphill, “Incidence and Nature of Puerperal Psychiatric Illness,” British Medical Journal 2 (1952): 1232. 15  Ibid., 1234. 16  Richard Gordon, “Emotional Disorders of Pregnancy and Child-bearing,” The Journal of the Medical Society of New Jersey 54 (1957): 16. 17  Richard E. Gordon and Katherine Gordon, “Some Social-psychiatric Aspects of Pregnancy and Childbearing,” The Journal of the Medical Society of New Jersey, 54 (1957): 569. 18  James Hamilton, Postpartum Psychiatric Problems (St. Louis, M O : The C.V. Mosby Company, 1962), 107. 19  For example see Hamilton, Postpartum Psychiatric Problems, 5–6. 20  James Hamilton, Prevention of Another Dark Century (presentation to 2nd Postpartum Support International Conference, 24 June 1988). Copy of presentation in possession of author; presentation provided by Jane Honikman. 21  Whiffen, “Is Postpartum Depression a Distinct Diagnosis?,” 485. 22  Examples of psychiatric researchers who focused their careers on P P D include Katherina Dalton, Robert Kendell, Michael O’Hara, and John Cox. See Godderis, “Managing Mad Mothers,” 106. 23  For an in-depth analysis of the addition of P P D to the d s m see Godderis, “Iterative Generation of Diagnostic Categories through Production and Practice,” 484–500.

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24  See the following references for further discussion of the “good mother” and the maternal ideal: Douglas and Michaels, The Mommy Myth; Hays, The Cultural Contradictions of Motherhood; Oakley, Becoming a Mother; Rich, Of Woman Born. 25 Nicolson, Post-natal Depression, 2. 26 Ibid. 27 Diamond, Roads to Dominion, 166. 28 Farber, The Rise and Fall of Modern American Conservatism, 119–22. 29 Diamond, Roads to Dominion, 165. 30 Ibid. 31  For a critical analysis of the “crack babies epidemic” see: Campbell, Using Women, 217–18; Karibo, “Constructing an Image.” 32  Godderis, “Grabbing the Media Spotlight.” 33  Honikman, interview with author, 24 June 2011. 34  Kendell, “Emotional and Physical Factors,” 3; E.S. Paykel, E.M. Emms, J. Fletcher, and E.S. Rassaby, “Life Events and Social Support in Puerperal Depression,” British Journal of Psychiatry 136 (1980): 340. 35  I am using the term “neoliberal” as it is defined in the governmentality ­literature, which was inspired by Foucauldian theory. For an explanation of different definitions of neoliberalism used in academic scholarship see Larner, “Neo-Liberalism.” 36  Rabinow and Rose, “Biopower Today,” 203. 37  Miller and Rose, Governing the Present, 74–6. 38  Ruhl, “Liberal Governance and Prenatal Care,” 95. 39  Kendell, “Emotional and Physical Factors,” 9. 40  Ibid., 7–9. 41  Carolyn Cutrona, “Nonpsychotic Postpartum Depression: A Review of Recent Research,” Clinical Psychology Review 2(1982): 495–7. 42  Ibid., 497. 43  Joyce Hopkins, Marsha Marcus, and Susan B. Campbell, “Postpartum Depression: A Critical Review,” Psychological Bulletin 95 (1984): 508–11. 44  Cutrona, “Nonpsychotic Postpartum Depression,” 494; Hopkins, Marcus, and Campbell, “Postpartum Depression,” 510; Kendell, “Emotional and Physical Factors,” 7; Gwen Stern and Laurence Kruckman, “Multidisciplinary Perspectives on Post-partum Depression: An Anthropological Critique,” Social Science and Medicine 17 (1983): 1031. 45  Anne Kingston, The Meaning of Wife, 9. 46 Oakley, The Sociology of Housework, 26–7. 47  Ruhl, “Liberal Governance and Prenatal Care,” 103.

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13 From Fixing to Enhancing Bodies: Shifting Ideals of Health and Gender in the Medical Discourse on Cosmetic Surgery in Twentieth-Century Canada Tracy Penny Light At the forty-fifth annual meeting of the Canadian Society of Plastic Surgeons held in the summer of 1991, there was a great deal of discussion about the ethics of cosmetic surgery. Controversy over the safety of breast implants was one driver of the conversation, and Dr Rob Cartotto, a resident in plastic surgery at the University of Toronto, wondered whether a procedure that was “entirely elective for nonfunctional reasons” was ethical given that the long-term effects of implants were unknown.1 Douglas Courtemanche, clinical professor of plastic surgery and associate dean of residency training at the University of British Columbia, noted that “some patients experience significant benefits because of cosmetic surgery” but thought that “doctors who counsel in favour of cosmetic procedures when it is neither warranted nor in the patient’s best interest” were a source of unease.2 Despite these concerns, Dr Ralph Manktelow, chair of the Division of Plastic Surgery at the University of Toronto, advocated forcefully for cosmetic surgery. He argued, Our society places a great deal of emphasis on two things – a certain level of physical conformity, and youth. Most of our esthetic procedures fall into those two groups. People who have a relatively ugly nose may have a problem coping with life. They may be very well balanced and well equipped, but they feel that the first thing everybody sees is their nose and nobody recognizes their

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character. Surgeons can do them a big service. Or you might have a woman in her 50s trying to find work in the job market. Whether we want to or not, we often discriminate against people on the basis of their age. These people are often extremely pleased [with the results of a cosmetic procedure] – more thankful, it often seems, than the person for whom you remove a ­melanoma …3 This discussion reflects a discourse that, by the late twentieth century in Canada, viewed cosmetic procedures as important interventions in upholding patient health. These interventions could be pursued to maintain both physical and mental states, which together, contributed to the overall health and well-being of citizens.4 This view of cosmetic procedures also points to the increasing role that wider societal ideals surrounding the body played in that discussion. The history of cosmetic surgery, then, is inextricably linked not only to the history of medicine in general and to surgery in particular, but also to the history of identity formation for women and men. It allows for important glimpses into the ways that alterations to the body have, over time, affected individuals’ abilities to manoeuvre in society, their agency, and their own perceptions of their bodies as healthy or not as well as into the ways that medical authority has enabled access to surgical interventions for different societal purposes. The ability of patients to access such procedures today is a significant concern for many feminist scholars. For instance, Virginia Braun and Leonore Tiefer discuss current trends in cosmetic surgery (and especially the increase in female genital cosmetic surgery) that promote the notion that women (and men) should alter themselves (even their genitalia) to look “normal.”5 They question whether the authentic need of patients for treatment can be determined in an increasingly medicalized society. The role of patients who were “once regarded as passive victims of medicalisation” and who “can now occupy active positions as advocates, consumers, or even agents of change”6 has changed. This also complicates the role of physicians, whose authority allows them to prescribe procedures and even medications to patients who can request them by name. As Nancy Tomes points out, the evolution of medical­ ization since the 1970s has enabled patients and doctors to enter into a  “continuous dialogue” around health. In addition, the politics of ­personal identity that emerged in the twentieth century (which accounts for positionality around statuses like gender, race, ethnicity,

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sexual orientation, etc.) “have made differentiating the authentic from the inauthentic need [for medical interventions] more difficult.”7 Determining whether the reasons for altering a body are authentic (because it is ill) or inauthentic (because it is healthy) is challenging. As is evident in Canadian doctors’ discussions of cosmetic surgery at the end of the twentieth century, their ability to determine need was complicated because of a variety of factors that pointed to an inextricable link between the role of the medical profession and societal norms and values. Yet, this was always the case. What is considered abnormal, deviant, or ill in some periods is considered normal in others. Indeed, this volume demonstrates the ways in which the medical discourse on health shaped the ways that gender was understood and performed in different times and places. The themes explored in Bodily Subjects – the way that health is wrapped up in ideas about embodiment and citizenship, how illness is defined and contested in different periods, and the authority and ideals that prescribe certain norms and values related to health – can all be observed in the medical discourse on cosmetic surgery in twentieth-century Canada and point to the complexities of making a determination about who should access cosmetic procedures and who should not.8 Using cosmetic surgery as a case study, I situate the themes of this book, embodied citizenship, defining and contesting illness, and authority and ideals, within the medical discourse on cosmetic surgery in Canada. This case study illuminates the ways that gender and health are inextricably linked and explores how the ways that they are understood are historically contingent. I explore how the medical discourse shifted over the course of the twentieth century by surveying the Canadian Medical Association Journal (c m a j ) 9 in the twentieth century for articles that dealt with cosmetic, esthetic, reconstructive, or plastic surgery.10 While the c m a j was not the only medical journal that existed in Canada during this period, it was (and is) the official professional vehicle of the Canadian Medical Association and, as such, provides insight into the ways that cosmetic surgery was viewed within the broader profession.11 This is an important aspect of this history because plastic surgeons existed in Canada in the nineteenth century, but the Canadian Society of Plastic Surgeons was not formed until 1947. As such, early surgeons developed many of the procedures that are now viewed as “part of the standard plastic surgery repertoire,” but in a context where they were not considered to be specialists but rather members of the broader medical profession.12

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At the beginning of the twentieth century, doctors in Canada who performed cosmetic surgical procedures focused primarily on “fixing” ambiguities or abnormalities (often constructed as deviance) of the physical body to make it “healthy.” Initially, this fixing was directed primarily toward children and male patients so that they could each perform their roles as citizens, or in the case of children, future citizens. Surgeons recognized both the physical and psychological threat to those who were marked as different because it could limit their ability to successfully move in the world. However, by mid-century they also recognized that women could benefit from procedures that allowed them to live up to societal ideals for them as productive citizens and performed procedures, such as breast augmentation, that would facilitate the same. In these cases, we are offered a glimpse into the ways that the performance of citizenship was linked to gender and societal beauty ideals that were important at the time. Being able to perform as citizens was important but so, too, was being healthy. The ways in which health and illness were defined shifted over the course of the twentieth century as scientific and surgical advances provided new opportunities for the profession to deal with conditions that were previously untreatable. This shift also opened up space for new diagnoses. In the case of women, doctors discussed the need for some women to pursue enhancements of otherwise normal (healthy) bodies to deal with psychological rather than physical issues that stemmed from societal expectations. As advances in surgical techniques developed, doctors were also able to enhance “abnormal” (deviant) bodies for cosmetic reasons, even when the underlying “abnormality” remained.13 The shift to a recognition of psychological as well as physical aspects of health allowed doctors to perform strictly cosmetic procedures under the guise of health. The ways that health and illness were defined and contested in this period depended largely on context as, over the course of the twentieth century, patients began to play a larger role in defining what illness for them as individuals looked and felt like. This reflected the emerging healthism, which preoccupied privileged individuals with all aspects of their personal health and allowed the medical profession to become “the gatekeeper for happiness and social well-being.”14 The ability of patients to define their own illness and request cosmetic procedures was facilitated by the authority of medical science that placed the power to decide when to perform surgery in the hands of doctors. In the case of both men and women, the rationale for fixing bodies revolved around their ability to perform hegemonic masculinity

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and femininity. The evolution of the discourse demonstrates the ways that, over the course of the twentieth century, the professional authority of medicine and the process of medicalizing the body were reflected in changing ideals (prescriptions even) for healthy, normal bodies. By documenting the ways that the medical discourse on cosmetic surgery shifted over time it is my hope to gain better insight into the reasons that lead patients today (I am concerned primarily with women but this also applies to men) to pursue cosmetic surgical procedures when their bodies are otherwise healthy. 15 As a medical historian, I have spent most of my career thus far exploring the dangers of surgical interventions in different time periods, and it is fascinating (and disturbing) to think that a patient today can simply “decide” to opt for a medical pro­ cedure that can potentially be dangerous to their “healthy” body.16 This phenomenon and the wider societal ideals that promote a specific beauty ideal for girls and women17 have prompted me to think about the ways in which the medical profession constructed normality in the past, the role that culture plays in such constructions, the agency that patients have in determining their own health, and how that process was gendered.18 Physicians have always used their professional authority to define the ideal, healthy (normal) body.19 Today, though, that authority is becoming increasingly complex as medical science is appropriated to sell products, and patients are increasingly demanding procedures (and medicines) to make them well on the basis of advertisements they see in popular culture. By unpacking the ways that doctors have understood the healthy, normal body as both a physical and psychological entity in the past, along with the various socio-cultural issues that have played a role in that understanding, we may be able to find effective ways to challenge desires to conform to a particular set of values. At the very least, we may be able to problematize the medicalization of the body today, rather than simply accept what the prescriptions promote for us in performing our gender identities as citizens, patients, and consumers.20

Constructing “Normal” Bodies: Embodied Citizenship By the turn of the twentieth century, doctors in Canada had established themselves as the scientific experts on the body.21 They used their expertise (professional authority) to define the ideal, healthy (normal) body and in their practices outlined the ways that both women and men should perform their duties as embodied citizens.22 Throughout the

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twentieth century (and, I would argue, even still today) men were constructed primarily as breadwinners and women as mothers. For men, it was important to be healthy because this meant that they were able enact their citizenship by providing economic support for their families. In their discussions of men’s health, doctors noted the importance of managing illness so that men could perform their proper role.23 For women, health was essential as they were responsible for reproducing the nation through the birth of future citizens. Doctors reinforced this notion by promoting means for women to be healthy during pregnancy as well as before and after parturition.24 Given the constructions of masculine and feminine citizenship, doctors were interested in finding ways to ensure that both men and women were healthy so that they could perform appropriately in society. Therefore, the proper roles that men and women were expected to play were upheld by practitioners whose ability to define such roles was rooted in their scientific practice of medicine.25 One of the key markers of a scientific approach was the sharing by doctors of cases of “abnormality,” whether caused by illness, disease, pathology, or even injury. These clinical case reports allowed physicians to legitimize their ability to restore the lost normativity of the body.26 They increasingly documented successful interventions and illustrated the cases before and after treatment, a trend that Nikolas Rose notes began in the nineteenth century. While disease itself was sometimes more difficult to document than outward physical abnormalities, the role that doctors played “in the mapping of disease in social space, [and the] collection of statistics on the illnesses of the population” among other things related to the maintenance of good health, helped to position the medical profession as the primary authority on health.27 Initially, doctors focused on documenting physical abnormalities, which became the purview of surgeons in the nineteenth century. The primary aim of this work was “to restore the body to its ideal prior state.”28 This ideal allowed recipients of reconstructive surgical procedures to “pass” as normal. As Sander Gilman notes, “‘Passing’ is a means of trying to gain control. It is the means of restoring not ‘happiness’ but a sense of order in the world. We ‘pass’ in order to regain control of ourselves and to efface that which is seen (we believe) as different, which marks us as visible in the world. Relieving the anxiety of being placed into a visible, negative category, aesthetic surgery provides relief from imagining oneself as a stereotype.”29

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The desire to fix those who appeared to be “other” in Canada dominated early discussions of surgical repairs and this was particularly important for children who had what Dr J.D. McEachern, chief surgeon at Winnipeg Children’s Hospital, described as “the most serious of congenital handicaps” – cleft palate and hare lip.30 While this deformity could lead to dangerous respiratory infections, McEachern argued that the physical consequences of the disability were probably outweighed by the potential for psychological problems. In his view, the surgeon had a large role to play in obtaining a successful cosmetic outcome. As he noted in 1928, “A bad cosmetic result makes him [the patient] an object of curiosity or even disgust to his associates, and the sound of his voice continually reminds him that he is different, or, as he often thinks, inferior to others. This malformation precludes the afflicted person from engaging in many lines of endeavour, and there are few occupations in which the individual with cleft-palate may engage without being greatly handicapped.31 Similarly, Dr H.O. Foucar, the chief of surgery at St. Joseph’s Hospital in London, Ontario, noted in 1933 that parents of children who were born with the deformity of a hare-lip experienced “one of the major trials in life … [upon] the arrival of an infant afflicted with a congenital facial deformity, to say nothing of the tremendous handicap under which the individual himself must labour with such a deformity.”32 Given the potential for children with this condition to be limited in their ability to participate in society effectively as adult citizens, this was an important malady to fix and indeed represented a large focus of early therapeutic and cosmetic surgical practice.33 While the fixing of children who were born with such deformities was important for both genders, what concerned McEachern most was that the condition was “slightly more common in boys than in girls.”34 Surgeons clearly recognized the importance for men to be able to perform their masculinity unconstrained by a physical abnormality and this was, therefore, an important condition to manage. Other deformities were also seen as particularly problematic for boys and men. In a report on congenital defects of the ear in 1940, Dr H.O. Foucar advocated for the early fixing of ears that appeared abnormal. He argued that measures should be taken in childhood because otherwise patients might become “morbidly self-conscious” as adults, preventing them from being successful.35 In other words, it was especially important for men to be able to pass in society to be successful.

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A case reported by Dr J.W. Gerrie in 1939 highlighted the economic dangers for men who were unable to pass. Gerrie, who would later become one of the founders of the Canadian Society of Plastic Surgeons, described the plastic surgery that he performed on a seventy-two-yearold Montreal businessman. The procedures to deal with what were described as “multiple facial disfigurements – rhinophyma, multiple warts and forehead lipoma,” were “simple and straightforward,” according to the surgeon.36 What is perhaps most notable about this case was Gerrie’s description of the social stigma and challenges faced by the patient. He remarked that the patient “did not relish inquisitive glances and veiled stares singling out his face as something not quite right” and that his appearance was causing his “business acumen” to suffer and prevented him from visiting his five daughters in Toronto because he feared inflicting his problematic appearance on them.37 In other words, it was impossible for Mr W. to “pass” as normal, which negatively affected his psychological health and his business ability. The connection was made between disease and sociological factors as Gerrie and his contemporaries observed the relationship between patients’ physical and psychological health before and after undergoing cosmetic procedures.38 In this case, after two surgical procedures, Mr W. was “a grateful patient” and had returned to his business and family activities.39 The case of Mr W. revealed that returning to normality could provide patients with both physical and psychological – even financial – benefits. As Dr Gerrie noted of Mr W.’s business acumen, the “latest reports are to the effect that some mechanical patent is in the process of being realized upon and that I am to cut in on the dividend.”40 In other words, as a result of the procedure, Mr W. was again able to perform his masculinity in a way that reflected societal norms and values in this period. The ability to effectively perform masculinity to adhere to societal norms and values was perhaps most evident in discussions by surgeons about how to fix soldiers who suffered injuries during the world wars. Indeed, many surgical innovations were prompted by the various wounds of soldiers in both world wars that called for “specialized methods of treatment and reconstruction beyond the repertoire of general surgery.”41 Repairing the damage of war that was visible on the faces and bodies of soldiers was an important factor that encouraged surgeons to develop the skills to tackle issues that were previously untreatable. Much of this work aimed to allow damaged soldiers to enter back into post-war society by minimizing their disfiguration, thus contributing positively to  their psychological state. It was also intended to help the broader

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society to avoid potential trauma from seeing the war-wounded. In other words, it allowed injured patients to “pass” after the wars ended by minimizing their difference and protected society from the horrors of war. However, as Dr J. Harold Couch of the Department of Surgery at the University of Toronto astutely observed in 1948, the problem rested more with society than with victims of injuries. In particular, he critiqued the response of the public to deformed individuals and lamented the fact that the response to “scars” often dishonoured, rather than honoured, the sacrifices that soldiers had made as citizens in fighting for the freedom of their country. “The scars themselves,” he noted, “are even more authentic evidence of wounds valiantly suffered, than are the golden wound stripes on the sleeve of a tunic.”42 Yet, this evidence of valour, he admitted, made it often difficult for the bearer to return to his place in the economic and social world in which he lived and, thus, it was the role of the surgeon to use his skills to help those who were disfigured to be “fit to appear” to the world.43 The techniques developed by surgeons, it was quickly realized, could also be used on civilians.44 Even more important than facilitating the re-entry of soldiers into society or allowing the average businessman to perform his gender was the need to fix the bodies of those on the margins. An interesting report appeared in the c m a j in 1965 that detailed the use of cosmetic surgery within a prison as a way to reduce criminal recidivism. In the study, 450 inmates (both male and female) were treated to fix congenital deformities or previously fractured noses.45 The hypothesis of the study, based on previous literature, was that plastic surgery would alleviate criminal behaviour because it would provide inmates with a more “normal” appearance, thus reducing the psychological issues that promoted their criminality. After the surgeries were performed, it was reported that “the beneficial psychological changes in these inmates were observed almost immediately. There was a marked inclination to co-operate with those in authority and to participate in prison activities. Formerly hostile and incorrigible individuals became polite and gracious in their manner … Among them a keen ambition developed to learn a trade and qualify for transfer to the vocational correctional centre. This ­subsequent heightening of morale and relief from hostility are two of the basic adjustments required for rehabilitation.”46 The suggestion that altering physical flaws or even abnormalities with cosmetic surgery could have positive psychological implications is an important one ­because, in this case, it represented a positive outcome for society more generally.

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Throughout the period, the importance placed on having healthy children able to pass in society and perform their duties as future citizens was visible in the discourse on cosmetic surgery. By the 1960s, though, advances in cosmetic surgery allowed surgeons to deal with newly appearing deformities in innovative ways. As John E. Hall, a member of the faculty in the Department of Surgery at the University of Toronto and assistant surgeon at the Hospital for Sick Children, noted in a discussion on the congenital malformations of thalidomide babies in 1963, “children with limb deficiencies have special problems which set them apart” from others with amputated limbs or musculoskeletal injuries but with proper treatment could be integrated “into society as productive members.”47 Other articles also discussed cosmetic surgery as a means of “fixing” abnormal bodies, including those born with ambiguous genitalia.48 The fixing of deformities, whether from congenital defects or even as the result of accident, was a long-standing part of the discourse on cosmetic surgery.49 By the last decades of the twentieth century, surgical procedures had advanced to the extent that doctors could fix bodies in ways not imagined in the early years of the century; doctors worked to alleviate the negative consequences of deformities for those most stigmatized by difference. Dr Ian Munro of the Division of Plastic Surgery at the Hospital for Sick Children reported in the c m a j in 1977 on the evolution of the subspecialty of craniofacial surgery that “permits correction of some of the most grotesque natural deformities.”50 Conditions such as “severe orbital hypertelorism, craniofacial microsomia, Apert’s or Crouzon’s syndrome, the Treacher Collins Syndrome, frontonasal dysplasia, as well as severe oxycephaly, plagiocephaly, and other unnamed cranial and facial malformations”51 caused the face and skull to be dramatically ­deformed. Dr Munro noted that physicians (and society) previously assumed that babies born with such deformities were mentally defective as well as physically deformed, causing them to be hidden from society. In fact, most of these patients had normal intelligence. Advances in surgical interventions allowed the physical defects to be treated and Munro reported that “almost every case [referred for treatment] has resulted in radically changed behaviour and achievement by these persons,” allowing such patients to live normal lives.52 In these cases, the abnormal physical conditions could increasingly be fixed to match the normal psychological and developmental state of the patient. However, such advances were also used to treat those who did have mental defects. Dr. Munro, for instance, used his expertise to correct

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craniofacial deformities of children with Down syndrome so that “the facial characteristics that immediately categorize them as mentally deficient” were removed.53 As the report noted, this surgical intervention was controversial because there was no evidence about “the long-term effect on the social integration of these children when their facial characteristics are changed.” Although the Hospital for Sick Children did set up a team of professionals to assess both the functional and the psychological aspects of the surgery, the goal, “to produce more out-going, happy, and self-confident children,” was questionable.54 While the patients might not be “readily identifiable as ‘handicapped,’” such surgery did not alter their condition. This is clearly a complicated (and perhaps even disturbing) notion – the desire to make the abnormal appear to be normal. As Barbara Brookes points out in her chapter on disabled children, there are many factors at play particularly when families must deal with an abnormal child (see chapter 7). The parents who consented to such procedures for their children with Down syndrome were presumably desiring “healthier” lives for them, which could be achieved (they hoped) by removing the visibility of their disability, thereby allowing them to pass in society.55 Obviously, in these cases the issue is less explicitly about gender than about societal discrimination against difference and the ability of such patients to perform roles as normal citizens in society. At the time of these procedures, children with physical and mental defects were viewed as having a problem to be “fixed” – today, the notion that someone with a disability needs this is contested because the discourse of disability studies argues that the notion of “disability” itself is a social construction. Many advocate increasing dialogue that problematizes what is normal and natural, rather than moving to fix someone who does not seem to fit societal prescriptions.56 Much of the history of cosmetic surgery published elsewhere has focused on the ways that procedures targeted women to allow them to live up to societal prescriptions for femininity and beauty.57 This was certainly visible in the Canadian discourse after mid-century. In several articles, doctors noted that women could benefit from operations that normalized the body, allowing them to better perform their roles. In an article from 1966, Dr J.B. Costello and Dr E.J. Badre, both attending staff at St. Vincent’s Hospital in Vancouver, British Columbia, described the case of a woman who required surgery to construct a vagina. The woman, Miss T, was described as “an 18-year-old girl [who] was seen in consultation because of amenorrhea.”58 When the surgeons examined her and discovered that she did not have a vagina, and knowing that she

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intended to marry, they recommended that an artificial vagina be ­constructed. In this case, it is clear that the doctors recognized that the patient would not be able to perform her role without a surgical intervention. In a 1973 article outlining breast surgeries, another case where a surgical intervention seemed necessary to allow a woman to better perform her femininity appeared in the c m a j . Dr M.T. Richards reported the case of a woman, Mrs A.H., a thirty-six-year-old “career woman” whose breasts were determined to be clinically healthy. Mrs A.H. insisted that they were not and that a procedure was required to normalize her. As the report notes, “a little encouragement brought out the statement that she felt she was fighting a losing battle for the attention of her male colleagues and especially of her husband because of her lack of bust endowment.” Once the patient was referred for breast augmentation (which was performed as an office procedure) the patient had “been a happy woman ever since.”59 By the early 1970s, more than a third of the total labour force in Canada was female and there were increasing calls for equality that stemmed from the efforts of the second-wave feminist movement. Given this shifting context, it is perhaps not surprising that some women were willing to alter their bodies to get ahead in the work world and to better perform their role as citizens.60

From Fixing to Enhancing Bodies: Defining and Contesting Illness The societal pressure that Mrs A.H. felt led to her own determination that her breasts were inadequate and, therefore, not normal. Her insistence that there was something unhealthy about her body was evidenced by her attendance at the office “on several occasions with numerous complaints, none of them real. On examination no abnormalities were detected; the breasts were very small but clinically healthy.”61 Mrs A.H’s refutation of the health of her body was not an isolated event. As Dr  Richards noted, other patients also contested the diagnosis of the physician. Mrs P.S. presented herself for an opinion on a lump she found in her breasts. Despite a diagnosis that indicated “clinical mastitis” and a mammography report that confirmed same, Mrs P.S. continued to return to the office frequently over five months “under various pretexts” but eventually admitted to being constantly worried about the lump. After the lump was finally removed and a pathological report was produced that indicated that her lump was benign, the patient “became

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happy again.” This was not the only such case: Dr Richards noted that fifty-two other patients had had similar experiences and he found that excising the “lumps, cysts, moles, etc.” and producing pathology reports that were absent “of the word ‘cancer’ or else [contained the statement] ‘no evidence of malignancy’ in black on white is a superb therapeutic agent.”62 In other words, women asserted their agency and contested the diagnoses of their physicians to obtain proof that they were not ill, allowing them to feel healthy. Other patients who actually experienced physical illness contested their doctors’ recommendations for therapy. For instance, Mrs K.B., despite having been diagnosed with breast cancer that was confirmed via a lumpectomy, refused to have her breasts surgically altered with a mastectomy. In her case, Mrs K.B. refused to conform to a medical prescription. As the case report notes, she “flatly refused hospitalization, surgery or irradiation strictly because ‘God placed me on this earth with two breasts and He will take me away with them.’”63 Mrs K.B. is a unique example because in her case, while she had a genuine therapeutic reason – to prevent the spread of cancer – for fixing her body, she ultimately decided not to seek the prescribed medical intervention. Other patients felt different types of pressure to conform to societal norms and viewed their bodies as abnormal. O.S. was a fifteen-year-old boy suffering from gynecomastia, a condition where the male breasts are overdeveloped. Given the abnormal appearance of his breasts, the case report notes that he was “extremely shy.” It explained the details of the patient’s trouble: “The leading complaint was that the boy was becoming progressively more withdrawn, would not attend swimming classes or go to the beach, as he had previously enjoyed doing, skipped P.T. classes and would not even wear a T-shirt or take his shirt off in the presence of anybody. The reasons were the questions, nicknames, and ribbing levelled at him, such as: ‘Are you a girl?’, ‘Where’s your bra, Charlie?’, ‘Hey, Broad!’, and ‘Half-man, half-woman.’”64 Obviously, such torments were incredibly intimidating to a youth coming of age in the 1970s. As Thomas Wendelboe points out in chapter 10, the 1970s were a period of debate about hegemonic masculinity and it is perhaps not surprising that peers would single out a young man when he did not conform physically to the ideal. In this case, the patient was so afraid of others’ views of him and his “abnormal” body that he pleaded not to go to the hospital for the mastectomy “because he did not want anybody to see his condition.” As such, his procedure was ­performed in the doctor’s office. These cases reveal the range of

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perspectives on body-altering procedures – from fixing to enhancing – that were present by the 1970s in Canada. Dr Richards’ report on breast surgery reveals much about the prevailing views of the value of breasts from the perspective of both males and females: for women, they were “highly important structures, both functionally and aesthetically” and could be a cause for worry whether they were healthy or diseased. On the other hand, breasts in men were viewed as a concern only if they were “abnormal” as in the case of gynecomastia, or if they were cancerous.65 Obviously, there are important gender differences espoused in this case report – for women, breasts are important beauty assets. For men, breasts represent an abnormality of the body and are thus deviant. Dr Richards conceded, though, that health was a fluid concept and that the “the final decision [about how to manage issues of abnormality, whether it was to augment otherwise healthy breasts, or remove diseased or abnormal breasts], rests with the owner.”66 These cases point to the ways that patients viewed their own bodies and the agency that they exerted over medical practices and procedures. By the mid-twentieth century, some women were advocating that they undergo cosmetic procedures to enhance their appearance in the absence of a physical health problem to effectively perform their femininity.67 Doctors were willing to provide such procedures, but by the late 1950s, it is clear that they were aware that careful psychiatric screening was needed to ensure that patients who sought out cosmetic procedures were not suffering from characteristics of marked narcissism and did not exhibit “traits of emotional immaturity, passivity and dependency.”68 The challenge for doctors, of course, was determining how these issues were fuelled by social and cultural factors and how these factors affected patients’ ideas of embodiment because their medical authority dictated that they needed to make the right decisions to maintain their patients’ health.69

C o s m e t i c S u r g e ry a n d t h e M e d i c a l i z at i o n o f t h e B o dy : A u t h o r i t y a n d I d e a l s Despite the possibility of positive psychological outcomes as a result of surgical procedures, doctors also recognized that many patients sought out these procedures because of a variety of neuroses.70 In a 1957 ­discussion of the “psychiatric aspects of cosmetic surgery of the nose,” Dr Karl Stern and his associates, members of the Institut Albert-Prévost

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in Montreal, noted that researchers stressed “the importance of establishing an intimate co-operation between surgeon and psychiatrist in cases of cosmetic surgery” because “the rising popularity of cosmetic surgery in recent years makes it important to draw attention to the possible neurotic motivations and psychiatric hazards associated with such operations.”71 To support their argument, they outlined a case report of a patient who, unlike the patients described above, was not happy with the results of her rhinoplasty and as a result suffered “a serious depressive reaction, obsessive-ruminating thinking, and extreme vindictiveness against the surgeon, all in spite of an apparently successful operation.”72 The authors situated their determination of the patient’s issues within the broader context of cosmetic surgery of the nose, which they suggested was more likely to be effective on men. They argued that if men exhibited an “undue preoccupation with external appearance” they were regarded as “neurotic” and, therefore, identified as ill-suited candidates for the procedure. In contrast, it was apparently not atypical for women to behave neurotically.73 The authors also connected “neurotic feelings of inadequacy” to reasons for cosmetic surgery. In this case the patient admitted that the idea for surgery had come from a magazine article. Further confirmation from the surgeon who performed the procedure that “television actresses, dancers, and models” had also undergone similar procedures and were happy with the results led her to go under the knife. In this case, it seems that the patient’s feelings of inadequacy were exacerbated by a desire to measure up to the appearance of celebrities.74 Elizabeth Haiken’s exploration of the history of cosmetic surgery in the United States reinforces the point that throughout the twentieth century, the widespread adoption of cosmetic surgery represents a conformism to a standard of perfection that was intensified by consumer culture and the wider public discourse on cosmetic surgery.75 This allowed for the focus of cosmetic procedures to shift from one that aimed primarily at transforming defective bodies to one that sought ways to improve already healthy ones. At the same time, new pressures were placed on surgeons to exercise their authority in a landscape complicated by the authority of wider public discourses on health.76 In a discussion of the new abilities for surgeons to perform liposuction in 1986, Dr Lefter Mantse pointed to the impact that the authority of cultural ideals of beauty had on his practice. He noted that women were increasingly seeking the ability to spot-reduce fatty areas of their

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bodies and this desire was reinforced by “the beauty industry [which] contributes significantly to making women who are ‘heavy around the middle’ feel unhappy and self-conscious. Today’s woman dreams of having a slim, almost emaciated, figure. To achieve this she turns to all sorts of products and methods.”77 For his part, he advocated the removal of fat via a vacuum, which he claimed was a “simple” solution for removing subcutaneous fat, despite the fact that the procedure represented “a radical departure from traditional surgical procedures.”78 Regardless of the methods that were employed to deal with what were perceived to be abnormal bodies, it is clear that doctors increasingly noted that psychological causes were responsible for (primarily) women’s desire to improve their appearance, either because their neuroses led them to overeat and thus caused a physical need for change, or because they disliked their appearance more generally, necessitating surgical intervention. Indeed, liposuction was just the tip of the iceberg in terms of the availability of cosmetic surgery by the late twentieth century. From blepharoplasty (lifting of the eyelids) to more recent interests in labiaplasty (alteration of the size or proportion of the labia),79 women could (and can) pursue many avenues to physical perfection. Most women today do not seek to fix actual physical deformities although doctors at times refer to normal physical variety (such as wide variations in labia size and shape or different body types) as such.80 Instead, more and more are seeking various cosmetic procedures to deal with their weight, natural changes that occur as a result of aging (for instance, Botox injections for wrinkles and more invasive procedures such as facelifts), or augmentation or alteration of body parts they perceive to be inadequate or in need of “rejuvenation.”81 The ability of patients to request procedures to deal with perceived inadequacies is a product of the contemporary phenomenon of healthism, where individuals are preoccupied with all aspects of their personal health. Yet at the same time, individuals increasingly demand control of their bodies to make them “healthy” in a way that allows them to dictate how health feels to them. In other words, patients request procedures to alter their bodies to “feel better.”82 As Robert Crawford notes, “when life is experienced as eluding control … the need for personal control is intensified. Personal health has become one such area into which people can throw their energies and reassert the sense that they can act on their own.”83 Of course, doctors are in the position of  having to determine whether the patient seeking out a cosmetic

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procedure is a rational chooser of body modification or whether they are irrational and overly obsessed with their bodies.84 By the late twentieth century, some doctors viewed the shifting relationship with their patients as positive. As Dr Ralph Manktelow noted in 1991, “We’ve come a long way in terms of how the doctor deals with the patient. In the good old days it was felt on both sides that the doctor would say, ‘this is what you should have done,’ and the patient would say, ‘Let’s do it.’ Now, I think it’s more appropriate that the patient be able to make a decision about the care based upon what the chances are that the operation will improve them, and what the risk factors are.”85 This perception that the negotiation between doctor and patient was a new phenomenon was, as we have seen, not completely accurate. Patients throughout the period under study asserted their agency with their doctors when it came to their bodies, at times challenged their professional authority, and often convinced their surgeons to perform procedures even when they were not strictly medically necessary. By the 1990s, cosmetic surgeons began to feel pressure to legitimize their authority as medical professionals. Shifting governmental views on the taxation of elective procedures and the ability of doctors to advertise their services all factored into increased pressure on cosmetic surgeons to assert their authority.86 As D. Lefter Mantse, the Ottawa surgeon who was “heavily involved in liposuction and hair transplantation,” pointed out, the issue revolved around how cosmetic procedures were viewed by society (and in this case, the government). This reflected the shift that occurred over the twentieth century from the view of cosmetic surgery as a means to fix abnormalities to the view that it was a means to enhance already healthy bodies. In this shift, a focus on the overall health of the patient – both their physical and their psychological health – was paramount. Mantse noted of societal views on the practice, “They can say that it is cosmetic, that it is unnecessary, that only vain people have it done, but they do not mention that psychiatric problems very often accompany these ‘cosmetic’ problems, that young men will drop out of school because their premature baldness bothers them so much. I have operated on men and the operation literally changed their whole life.”87 It is interesting that Mantse uses the example of male patients here, which suggests that both women and men were pursuing cosmetic procedures to live up to societal ideals. The ability of patients to live up to the prescriptions for femininity and masculinity was an issue clearly reflected in the discourse throughout the twentieth century. Early on, those prescriptions revolved around

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the ability of men and women to perform their duties as citizens. By the late twentieth century, that was still a factor but it is clear that the discourse reflected wider societal trends that enforced the ideal that looks and beauty were central to success. Part of this discussion appeared in  the early 1990s around the ability of surgeons to advertise their ­services.88 While some questioned the ethics of advertising, particularly the use of before and after photographs, others argued that, “after the scalpel the camera is probably the most important tool in the plastic surgeon’s armamentarium. Clinical photographs are necessary for comparison, teaching, legal and operative planning, scientific publishing and now advertising.”89 The shift toward advertising services, though, represented a major departure from earlier periods as it allowed surgeons to provide “evidence” of their ability to transform bodies that previously was only available in medical journals. While this helped to reinforce the authority of surgeons to provide such procedures it also opened up the possibility for some physicians to advertise themselves as “cosmetic surgeons” even when they were “not formally qualified to perform surgery,”90 which became a major concern that the profession continues to deal with in the twenty-first century.

Conclusion Throughout the twentieth century, it is clear that the authority of medicine and the wider societal ideals for men and women were embedded in the Canadian medical discourse on cosmetic surgery. In all of the cases, whether discussions about the need to repair or reconstruct some deformity or injury, or about the desire of patients to be altered for strictly cosmetic purposes, the ways in which society viewed men and women and what was valued in terms of their appearance were central to the discussion. It is clear that doctors at times wrestled with their authority and at other times embraced it. Yet, by the last decades of the twentieth century, the social context in which physicians operated had shifted substantially because of increased healthism and medicalization.91 The idea that health is not a static concept and that different sociocultural contexts dictate how the medical profession and, indeed society itself, defines health can be an unsettling idea, particularly when we  view medicine as scientific. Today, the professional authority of ­medicine continues to be appropriated to sell products that will make us “healthy.” Perhaps more problematic is the way that patients are increasingly demanding procedures (and medicines) to make them well (better, esthetically pleasing) on the basis of advertisements they see in

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popular culture, some of which come from doctors themselves. This shift in the societal discourse on health makes it important that we document the implications of this history so that we can make educated decisions about our bodies.92 This chapter begins to explore the surgical procedures that allowed physicians to alter the body and “normalize” it and how they evolved over the course of the twentieth century. The shifts that occurred in both the ways that doctors viewed cosmetic surgery and the ways that patients sought it out reflected the changing cultural landscape in which doctor and patient operated. While this was true in all periods, by the 1990s, doctors more forcefully argued that there was a societal need for cosmetic surgery, not just for reconstructive or reparative purposes but for enhancement itself. In other words, actual health, typically understood as the absence of illness, became less important than cosmetic appearance. The shift to enhancing appearances for “health” purposes is part of a larger story of the need to erase difference in Canada, a desire that is highly gendered. This complex interplay of factors that influence what it means to be healthy and the ways that gender is embedded in the culture in which the medical profession defines what is normal is evident in the history of cosmetic surgery. Medical advances push the boundaries of what it means to be healthy, making new surgical procedures possible. However, just because it is possible to alter our bodies does not necessarily mean that we ought to. Understanding the ways that the concept of health shifts and changes over time in light of new medical practices may help us to challenge or, at least problematize, the medicalization of the body today and the societal prescriptions that work together to prescribe how we are to perform our gender identities. Perhaps such understandings will open up new spaces for us to critique the authority of the various messages that we are subjected to as embodied citizens, to define illness in a way that honours our ability to determine health for ourselves, and to ask critical questions about the authority and ideals embedded in our contemporary cultural context that seek to normalize us. By doing so, we may be able to eliminate perceptions of inadequacy altogether, thereby normalizing difference.

Acknowledgments I thank Wendy Mitchinson and Barbara Brookes and the anonymous peer reviewers for their comments on earlier versions of this chapter. Thanks also go to all of my colleagues and students in the Sexuality,

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Marriage, and Family program at St. Jerome’s University, whose questions and activism around the normalization of the body through ­cosmetic surgical practices prompted me to explore the history of these practices. Finally, thank you to the Canadian Institutes of Health Research, St. Jerome’s University, the Faculty of Arts and the History Department at the University of Waterloo, and the University of Otago for providing funding in support of this project.

notes   1  Thomas P. Keenan, “Ethical Issues at Forefront as Canada’s Plastic Surgeons Meet,” c m a j 145, no. 8 (October 1991): 1029.  2 Ibid.  3 Ibid., 1031.   4  The World Health Organization defined health in 1948 as “a state of ­complete physical, mental and social well-being and not merely the absence of disease or infirmity.” See the Introduction to this volume; Crawford, “Healthism and the Medicalization of Everyday Life.”   5  For instance, see Braun, “Female Genital Cosmetic Surgery”; Braun “The Women are Doing It for Themselves”; Braun and Tiefer, “The ‘Designer Vagina’ and the Pathologisation of Female Genital Diversity.”   6  Metzl and Herzig, “Medicalisation in the 21st Century,” 697.   7  Tomes, “Patient empowerment and the dilemmas of late-modern medicalisation,” 699.   8  Kathy Davis wrestles with this complexity in her work as well. See Davis, Reshaping the Female Body; Davis, Dubious Equalities.   9  For this case study, I surveyed the Canadian Medical Association Journal over the course of the twentieth century for any articles that dealt with cosmetic, esthetic, reconstructive, or plastic surgery. The Canadian Society of Plastic Surgeons was not formed until 1947 and the Canadian Journal of Plastic Surgery was not established until 1993. As such, I was most interested in the view of the broader Canadian Medical Association for this preliminary research. In future work, I intend to explore these issues more broadly by including other journals, such as the Canadian Journal of Surgery, which was established in 1957. 10  I use the term cosmetic surgery throughout the chapter despite the shifting meaning of this term over the course of the twentieth century. Throughout the period, the term was used in Canada to refer to surgical practices that altered the physicality of the body – this was done in ­different periods to address physical abnormalities and in others to

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enhance already healthy bodies. The shifting nature of the term itself suggests a need to problematize the way the practice was understood in different periods to better complicate the various procedures that are sought out today. 11  The Canadian Society of Plastic Surgeons was not formed until 1947 and the Canadian Journal of Plastic Surgery was not established until 1993. 12  Leith G. Douglas, History of the Canadian Society of Plastic Surgeons, 3. 13  Given their medical authority over the body, doctors determined whether “abnormality” existed in the bodies of men and women. 14  Crawford, “Healthism and the Medicalization of Everyday Life,” 381. 15  For instance, see Braun, “Female Genital Cosmetic Surgery”; Braun, “The Women are Doing It for Themselves”; Braun and Tiefer, “The ‘Designer Vagina’ and the Pathologisation of Female Genital Diversity.” 16  Many doctors also share this concern. In 2008 Dr David Kester, president of the Canadian Society for Aesthetic Plastic Surgery, noted that elected cosmetic procedures were not trivial procedures. “The fact is,” he noted, “a tummy tuck is every bit as stressful and risky as having your uterus removed. It’s a 2 to 3 hour procedure with all of the complications of major surgery.” Dan Lett, “The Search for Integrity in the Cosmetic Surgery Market,” c m a j 178, no. 3 (January 2008): 275. 17  There is excellent work in this area by feminist scholars. For instance, see McRobbie, “Young Women and Consumer Culture”; Gill, “From Sexual Objectification to Sexual Subjectification”; Murray, “Branding ‘Real’ Social Change in Dove’s Campaign for Real Beauty.” 18  While the case of female genital cosmetic surgery has garnered much ­attention from academics in the recent past, it should be noted that men, too, are held up to a hegemonic ideal about how they should look. Procedures like pectoral implants or penis enhancements suggest that men may be equally subjected to invasive procedures in their quest to live up to an ideal. 19  I have explored this in earlier work on Canada and the United States. See Penny Light, “Consumer Culture and the Medicalization of Women’s Roles” and “‘Healthy’ Men Make Good Fathers.” 20  This is particularly visible in the emergence of cosmetic surgery clinics that advertise the “normalization” of bodies through a variety of surgical interventions. It also points to the increasing blurring of the line between the interests of doctors in their patients’ health and the interests of large pharmaceutical companies in selling their products. For a discussion of this see Moynihan and Mintzes, Sex, Lies and Pharmaceuticals; Canner, Orgasm Inc.

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21  Penny Light, “Consumer Culture and the Medicalization of Women’s Roles.” For a good overview of the professionalization of medicine, see Gidney and Millar, “The Origins of Organized Medicine.” 22  For instance, in Canada see Mitchinson, The Nature of Their Bodies; Gleason, Normalizing the Ideal; Chenier, Strangers in Our Midst; Adams, The Trouble with Normal. For examples from the United States, see Reis, Bodies in Doubt; Meyerowitz, How Sex Changed. 23  For instance, see the work of Patricia Reeve in chapter 1 of this volume. On the history of masculinity in Canada more generally, see Dummit, The Manly Modern. For a connection between the performance of gender roles, masculinity, and heart disease, see Riska, Masculinity and Men’s Health; Penny Light, “‘Healthy’ Men Make Good Fathers.” 24 Comacchio, Nations Are Built of Babies; Arnup, Lévesque, and Pierson, Delivering Motherhood; Baillargeon, Babies for the Nation; Mitchinson, The Nature of Their Bodies; Mitchinson, Giving Birth in Canada. 25  The establishment of the regular medical profession as the authority on the body was central to their ability to determine markers of health and i­llness and methods of treating same. Indeed, the differentiation of “regular” doctors who were scientifically trained and those “irregulars” who were not was the key to the positioning of the medical profession as the authorities on health and the body by the turn of the twentieth century. For discussions of the regulation of the medical profession in Canada, see Gidney and Millar, “The Origins of Organized Medicine”; Howell, “Elite Doctors and the Development of Scientific Medicine”; Shortt, “Physicians, Science, and Status”; Mitchinson, The Nature of Their Bodies; Blishen, Doctors in Canada. 26  Rose, “Beyond Medicalisation,” 701. 27  Ibid. Rose also notes that doctors were involved in areas like the regulation of food and the design of effective sewage treatment methods. In short, they were instrumental in determining ways for society to promote good health in the nineteenth century. For an interesting discussion of statistics and health, see Brigitte Fuchs’ discussion of osteomalacia in chapter 5 of this volume. 28 Gilman, Making the Body Beautiful, 10. See also, Haiken, Venus Envy. 29 Gilman, Making the Body Beautiful, 331. 30  For instance, see J.D. McEachern, “The Problem of the Child with HareLip and Cleft-Palate,” c m a j 18, no. 2 (February 1928): 170–4; Fulton Risdon, “Surgical Treatment of Hare Lip and Cleft Palate in Children,” c m a j 25, no. 5 (November 1931): 563–5; E.F. Risdon, “Surgical Repair of Facial Injuries and Harelip and Cleft Palate Deformities,” c m a j 32, no. 1 (January 1935): 51–4.

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31  McEachern, “The Problem of the Child with Hare-Lip and Cleft Palate,” 170. 32  H.O. Foucar, “Hare-Lip,” c m a j 28, no. 4 (April 1933), 373. 33  Douglas documents this in his History of the Canadian Society of Plastic Surgeons, 5. 34  McEachern, 170. 35  H.O. Foucar, “Congenital Abnormalities of the External Ear,” c m a j 43, no. 1 (July 1940), 27. Foucar does not say whether this was a problem for men specifically, but instead notes that procedures could be performed on “children and adults.” However, the figure depicting a before and after ­image was that of a man. One might assume that this defect could be potentially less problematic for women, whose hair might cover their deformed ears. 36  Rhinophyma is a condition where the sebaceous glands on the tip of the nose have progressively atrophied, often from untreated rosacea. The nose appears as large and bulbous, and the condition is sometimes aggravated by alcoholism. J.W. Gerrie, “Plastic Surgery at Seventy-Two,” c m a j , 41, no. 6 (December 1939): 548. 37 Ibid. 38  Ibid. See also Gilman, Making the Body Beautiful. 39  Gerrie, 549. 40 Ibid. 41 Douglas, History of the Canadian Society of Plastic Surgeons, 9. See also Peter Wilton, “WW II ‘guinea pigs’ played crucial role in refining plastic surgery in Canada,” c m a j 159, no. 9 (November 1998): 1158–9. 42  J. Harold Couch, “The Psychology of Reconstructive Surgery,” c m a j 59 (July 1948): 12. 43  Ibid., 13. 44  Gilman discusses the various procedures developed during wartime and the surgeons who pioneered the techniques in Making the Body Beautiful, chap. 5. 45  Edward Lewison, “An Experiment in Facial Reconstructive Surgery in a Prison Population,” c m a j 92, no. 6 (6 February 1965): 251–4. For a detailed account of the role of surgeons in repairing noses for the purposes of “passing” see Gilman, Making the Body Beautiful. 46  Lewison, “An Experiment in Facial Reconstructive Surgery,” 253. 47  John E. Hall, “Habilitation of Patients with Congenital Malformations Associated with Thalidomide: Surgery of Limb Defects,” c m a j 88 (May 1963): 964. 48  For instance, Editorial, “Change of Assigned Sex After Infancy,” c m a j 90 (29 February 1964). A rich body of literature explores the history of

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“fixing” abnormal genitalia. For instance, see Meyerowitz, How Sex Changed; Reis, Bodies in Doubt. 49  For instance, an article that appeared in the c m a j in 1911 noted that “rapid strides are being made in what might be called constructive surgery.” The focus of this early article was on advances in the “free transplantation of bone and other tissues” that would allow doctors to deal with the replacement of joints and bones. This would become increasingly important during the Great War and, as the history of the Canadian Society of Plastic Surgeons reports, quickly expanded to include all other types of deformities. See “Rapid Strides Being Made in Constructive Surgery,” c m a j 1 (1911): 368–9; Douglas, History of the Canadian Society of Plastic Surgeons. 50  Ian R. Munro, “Craniofacial Surgery: A Change of Face,” c m a j 117 (6 August 1977): 210. See also Ian R. Munro, “The Ugly Face: Deformity not Defectiveness,” Canadian Family Physician 19 (1973): 57; Ian R. Munro, “Orbito-Cranial-Facial Surgery: The Team Approach,” Plastic Reconstructive Surgery 55 (1975): 170; L.A. Whitaker, I.R. Munro, and I.T. Jackson, and K.E. Salyer, “Problems in Craniofacial Surgery,” Journal of Maxillofacial Surgery 4 (1976): 131. 51  Orbital hypertelorism refers to increased distance between the eyes and a symptom of a variety of syndromes including Crouzon syndrome. Crouzon syndrome results from the inability of the skull and facial bones to develop properly while in development, leading to malformations of the skull and face. Craniofacial microsomia is a term used to describe a spectrum of abnormalities that primarily affect the development of the skull (cranium) and face before birth. Apert syndrome is a congenital disorder characterized by malformations of the skull, face, hands, and feet. Treacher Collins syndrome is a rare congenital disorder characterized by craniofacial deformities, such as absent cheekbones. Frontonasal dysplasia results in distinct nasal deformities. Severe oxycephaly is a congenital condition that refers to abnormal development of the head. Plagiocephaly is an asymmetrical distortion of the skull. 52  Munro, “Craniofacial Surgery,” 210. 53  Rosalind Labow, “Toronto Plastic Surgeon Now Performing Operation to Correct Facial Defects of Down’s Syndrome Children,” c m a j 128, no. 6 (15 March 1983): 642. 54 Ibid. 55  Kathy Davis also discusses this phenomenon although much later in 2002 in Dubious Equalities, 135–8. This is clearly an ethical issue wrapped up in the ability of the patient to consent to the procedure and raises

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complicated questions about who should be able to access these procedures in the twenty-first century. 56  This, of course, has been a major concern of activists who point to the problems with dealing with ambiguous genitalia. See Reis, Bodies in Doubt; “Impossible Hermaphrodites”; Meyerowitz, How Sex Changed. For a compelling contemporary perspective on “fixing” abnormal bodies from a patient’s perspective, see Amie’s website “Reflections on Treacher Collins Syndrome,” http://www.treachercollins.org/tcs/About_Me.html. Amie is a medical doctor who has Treacher Collins syndrome. 57  See, for instance, Morgan, “Women and the Knife”; Davis, Reshaping the Female Body; Dubious Equalities; Haiken, Venus Envy; Gilman, Making the Body Beautiful. 58  J.B. Costello and E.J. Badre, “Construction of an Artificial Vagina,” c m a j 95 (September 1966): 631. 59  M.T. Richards, “Breast Surgery … as an Office Procedure,” c m a j 109 (August 1973): 306. 60  Of course, this raises an important tension that existed between attempts by second-wave feminist to push back against the sexual objectification of women and the reality that some women felt, even then, the need to perfect their bodies to compete in a traditionally male-dominated work world. That tension seems to be even greater today with the ubiquitous nature of presentations in the media of sexually charged images of women. Ariel Levy discusses this tension in Female Chauvinist Pigs. See also Gill, “From Sexual Objectification to Sexual Subjectification”; McRobbie, “Young Women and Consumer Culture.” For a discussion of this period, see Owram, Born at the Right Time, 276. 61  Richards, “Breast Surgery,” 306. 62 Ibid. 63  Ibid., 305. 64  Ibid. It should be noted that while doctors in the c m a j do not appear to have been discussing issues related to gender, sexuality, and surgery at any great length, we know that by the 1950s, doctors were exploring issues of intersexuality primarily led by John Money and that by 1962, American psychoanalyst Robert Stoller had opened the first gender identity research clinic to explore “psychological sex.” For a more detailed discussion of this, see Joanne Meyerowitz, How Sex Changed. More research on these important issues from the perspective of the evolution of the medical discourse in Canada needs to be done. 65 Ibid. 66 Ibid.

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67  For instance, see Haiken, Venus Envy; Gilman, Making the Body Beautiful; Parker, Women, Doctors and Cosmetic Surgery. 68  Karl Stern, Andree Lariviere, and Guy Fournier, “Psychiatric Aspects of Cosmetic Surgery of the Nose,” c m a j 76 (15 March 1957): 470. 69  This issue continues to be at the heart of the debate on cosmetic surgical procedures, particularly those aimed at enhancement. Some scholars see cosmetic surgical practices as problematic because they strengthen traditional beauty norms while also putting women at risk. For instance, see Bartky, Femininity and Domination; Bordo, Unbearable Weight; Morgan, “Women and the Knife.” Others see their work as “a balancing act between a critique of the technologies, practices, and discourses that define women’s bodies as deficient and in need of change and a sociological understanding of why women might view cosmetic surgery as their best – and in some cases – only option for alleviating unbearable suffering.” Davis, Dubious Equalities, 5. 70  That cosmetic surgery is inherently connected to a person’s overall wellbeing is now a common discourse that has an important history. See Fraser, Cosmetic Surgery, Gender and Culture; Gilman, Making the Body Beautiful; Braun and Tiefer, “The ‘Designer Vagina’ and the Pathologisation of Female Genital Diversity”; Pitts-Taylor, Surgery Junkies. This connection between physical and psychological health can also be seen in Wendy Mitchinson’s work on the history of obesity in this volume (chapter 11). 71  Stern, Lariviere, and Fournier, “Psychiatric Aspects of Cosmetic Surgery of the Nose,” 469. Doctors increasingly discussed the role of psychology in medical practice in the early decades of the twentieth century but it became particularly prominent after the world wars. 72  Ibid., 472. 73  Ibid., 469. 74  Ibid., 470. There has been a great deal of research about the power of popular culture to reinforce prescriptions for femininity for women. For instance, see Bordo, Unbearable Weight; Peiss, Hope in a Jar; Penny Light, “Consumer Culture and the Medicalization of Gender Roles.” On cosmetic surgery specifically, see Davis, Dubious Equalities; Haiken, Venus Envy. 75 Haiken, Venus Envy, 15. 76  For a discussion of the complexities surrounding professional and public authority, see Penny Light, “Consumer Culture” and “‘Healthy’ Men Make Good Fathers.” 77  Lefter Mantse, “Liposuction: A New Body Sculpturing Procedure,” c m a j 135 (1 November 1986): 975.

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78  Ibid. Wendy Mitchinson describes the variety of methods that could be employed by physicians to deal with the desire of patients to lose weight in chapter 11 in this volume. These ranged from appetite-suppressing drugs to various surgical procedures, and these were shaped by wider cultural prescriptions for what a healthy body looked like that were often fuelled by the interests of pharmaceutical companies. 79  This seems to be becoming an increasingly popular procedure for women to pursue, with a multitude of websites dedicated to understanding the ­varieties of genital surgeries available. A Google search for “labiaplasty Kitchener-Waterloo” revealed at least one surgeon who provides genital surgery (up to four are noted in the searches), http://spasurgica.com/ SurgicalProcedures/LabialReduction. Many more surgeons who perform these procedures can be found in larger centres like Toronto. For instance, see http://www.plasticsurgeryinfo.ca/plastic_surgery_in_canada/ genital_surgery_canada.html. 80  In his description of the history of liposuction, Mantse refers to the desire to remove “riding breeches” as “deformities.” See “Liposuction.” 81  The practice of labiaplasty has generated much scholarly debate, particularly when the Western world condemns developing countries for performing genital mutilation. For discussions of female genital cosmetic surgery, see Braun, “Female Genital Cosmetic Surgery”; Braun, “The Women are Doing It for Themselves”; Braun and Tiefer, “The ‘Designer Vagina’ and the Pathologisation of Female Genital Diversity”; Karras, Petals. Leonore Tiefer also heads up the New View Campaign, which is aimed at educating the public about the problems associated with the rise of the pharmaceutical industry and the medicalization of sex. See http:// www.newviewcampaign.org/. 82  For a discussion of this specific to cosmetic surgery, see Davis, Dubious Equalities. 83  Crawford, “Healthism,” 382. 84  Carol Lee Bacchi and Chris Beasley, “Citizen Bodies”, 340. For an interesting discussion of the issues surrounding body modification, see Featherstone, Body Modification. 85  Keenan, “Ethical Issues,” 1031. 86  Patrick Sullivan, “G S T on Cosmetic Procedures Will Drive Patients Away, Surgeons Say,” c m a j 142, no. 1 (1990): 55–6; Rhonda Birenbaum, “There’s Nothing Wrong with Physician Advertising, Many Observers Say,” c m a j 146, no. 1 (1992): 53–5; Patrick Sullivan, “Plastic Surgeons Take Advantage of Relaxed Rules, Launch Ad Campaigns,” c m a j 146, no. 1 (1992): 55–6; Robert H. Stubbs, “Response,” c m a j 146, no. 8 (1992):

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1290. See also the letter to the editor that prompted this response from Kenneth J. Collier, “Plastic Surgeons Take Advantage of Relaxed Rules, Launch Ad Campaigns,” c m a j 146, no. 8 (1992): 1288 87 Ibid. 88  Robert H. Stubbs, “Response,” c m a j 146, no. 8 (1992): 1290. See also the letter to the editor that prompted this response from Kenneth J. Collier, “Plastic Surgeons Take Advantage of Relaxed Rules, Launch Ad Campaigns,” c m a j 146, no. 8 (1992): 1288; and Rhonda Birenbaum, “There’s Nothing Wrong with Physician Advertising, Many Observers Say,” c m a j 146, no. 1 (1992): 53–5; Patrick Sullivan, “Plastic Surgeons Take Advantage of Relaxed Rules, Launch Ad Campaigns,” c m a j 146, no. 1 (1992): 55–6. 89  Robert H. Stubbs, “Response,” c m a j 146, no. 8 (1992): 1290. For an interesting discussion of the use of photography in medicine historically, see Jonah Samson, “The Beauty of the Cure,” c m a j 166, no. 7 (April 2002): 939–40. 90  Dan Lett, “The Search for Integrity in the Cosmetic Surgery Market,” c m a j 178, no. 3 (January 2008): 274. 91  For an interesting discussion of medicalization in the twenty-first century, see the collection of articles in The Lancet 369 (2007): 697–707. 92  For a discussion of this see Moynihan and Mintzes, Sex, Lies and Pharmaceuticals; Canner, Orgasm Inc.

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Contributors

B a r b a r a B r o o k e s is professor of history at the University of O ­ tago. Her research centres on areas where the history of women and the history of medicine intersect. Her book, Abortion in England, 1900–1967, was reissued in 2012 by Routledge Library Editions: Women’s History. B r i g i t t e F u c h s is research associate at the Department of History of the University of Graz and a lecturer in gender studies at the universities of Vienna, Graz, and Salzburg. Her research interests are in the fields of gender, the intersectionality of race, class, religion, and gender, as well as of historical and contemporary anthropological and medical theorizing. Her more recent (English) publications include “Orientalising Disease: Austro-Hungarian Policies of ‘Race,’ Gender, And Hygiene in Bosnia and Herzegovina, 1878–1914,” in Health, Hygiene and Eugenics in Southeastern Europe to 1945, and “‘Bushmen in Hick Town’: The Austrian Empire and the Study of the Khoesan,” in Austrian Studies. C a t h e r i n e G i d n e y is adjunct professor of history at St Thomas University. She is the author of A Long Eclipse: The Liberal Protestant Es­ tablishment and the Canadian University, 1920–1970 (M Q U P , 2004) and Tending the Student Body: Youth, Health and the Modern University (forthcoming, University of Toronto Press). She is currently researching the history of commercialism in Canadian schools. M o n a G l e a s o n is professor in the Department of Educational Studies at the University of British Columbia. Her teaching and research ­focus on the history of education, children, and childhood. Her most

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recent book is entitled Small Matters: Canadian Children in Sickness and Health, 1900–1940 (MQUP, 2013).  R e b e c c a G o d d e r i s is an associate professor cross-appointed to the Health Studies and the Society, Culture & Environment programs at Wilfrid Laurier University. She has recently published in the Journal of the History of the Behavioral Sciences, Sociology of Health and Illness, and Culture, Medicine and Psychiatry. N a t a l i e L . G r av e l l e is a doctoral candidate in the graduate program in history at York University. Her dissertation explores community responses to the emergence of H I V /A I D S in Montreal, Toronto, and Vancouver between 1982 and 1996. A n t j e K a m p f , (P h D Auckland, MA Cincinnati), is currently associate lecturer in the History Department at Humboldt Universität zu ­Berlin. She was assistant professor for gender aspects of the history, philosophy, and ethics of medicine, and interim associate professor of the history of medicine at the Johannes Gutenberg-Universität Mainz (2006–13). She is the author of Mapping out the Venereal Wilderness: s t d and Public Health in New Zealand, 1920–1980 (L I T -Verlag, 2007), and co-editor of Aging Men, Masculinities and Modern Medicine (Routledge, 2012), and has published widely on the history of public health, aging, and gender in Medical History, Health: An Interdisciplinary Journal, The Journal for the History of Sexuality, Critical Public Health, Studies in Contemporary History, Body and Society, and Journal of Aging Studies. Her current research includes a larger historical study on the translation of breast and cervical cancer as a risk concept to the public in East and West ­Germany, from 1947 to the1990s, and a book project entitled “Male Infertility and Fatherhood: Medicine, Society and Masculinity in West Germany post W W I I ”. M a r j o r i e L e v i n e - C l a r k is associate professor of history and ­co-director of the Health Humanities Program at the University of ­Colorado Denver. She has published a number of scholarly articles and book chapters on relationships between gender, health, work, and social policy in nineteenth- and early twentieth-century Britain. Her first book, Beyond the Reproductive Body: The Politics of Women’s Health and Work in Early Victorian England (2004) appeared in Ohio State University’s series on Women and Health, and her second book, Unemployment,

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Welfare, and Masculine Citizenship: “So Much Honest Poverty” in Britain, 1870-1930 (2015) is part of Palgrave’s Genders and Sexualities in ­History series. W e n d y M i t c h i n s o n is professor emerita and adjunct professor at the University of Waterloo.  Most of her research has focused on the way medical practitioners have perceived and treated the female body. Her publications include The Nature of Their Bodies: Women and Their Doctors in Victorian Canada (1991), Giving Birth in Canada 1900–1950 (2002), and Body Failure: Medical Views of Women, 1900–1950 (2013). She is presently working on the history of obesity in Canada from 1920 to 1980. M e g P a r s o n s is a lecturer in environmental management at the University of Auckland (New Zealand). Her P h D was undertaken at the University of Sydney and she later worked at the Waitangi Tribunal in New Zealand and at the University of Melbourne and Griffith University in Australia. Her disciplinary background is in human geography and history, with a broad interest in indigenous histories, the social determinants of health, and climate change adaptation. While her P h D focused on the history of public health provisions to Queensland indigenous communities, her most recent research examines the ways in which climate change adaptation needs to take into account the wider histories of social and environmental change that have occurred in indigenous societies as a result of colonialism. T r a c y P e n n y L i g h t is director of Women’s Studies at the University of Waterloo and associate professor in the Sexuality, Marriage, and Family Studies and History departments at St Jerome’s University (University of Waterloo). Her current research explores how gender and sexuality are represented in and constructed by both the medical profession and the media in North America and the ways that technology influences women’s consumption of pornography. She is co-editor (with Jane Nicholas and Renee Bondy) of Feminist Pedagogy in Higher Education: Critical Theory and Practice (forthcoming, Wilfrid Laurier University Press). P a t r i c i a A . R e e v e is associate professor and director of American Studies at Suffolk University, Boston. Recent publications include “Intentional Teaching, Intentional Scholarship: Applying Backward Design Principles in a  Faculty Writing Group,” in Innovative Higher Education

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and “Mystic Seaport: The Museum of America and the Sea,” in Labor and Working Class History of the Americas. A n i k a S t a f f o r d completed her P h D with the Institute for ­Gender, Race, Sexuality, and Social Justice at the University of British Columbia. She is currently affiliated with the Department of History at Simon ­Fraser University where she is conducting S S H R C postdoctoral research on crossovers between children’s welfare, recreational programming, and psychiatrization of mother’s sexualities in Cold War Vancouver. She is the author of Is it Still a Boy? Heteronormativity in Kindergarten (forthcoming) and is co-editing the forthcoming anthology, Constructions of Risk: The Production of “At Risk” Bodies and Populations in Health, Education, and Community Services. Her article “Departing Shame: Feinberg and Queer/Transgender Counter-cultural Remembering,” published with the Journal of Gender Studies, was selected as one of the top ten contributions to the journal’s history. T h o m a s W e n d e l b o e is a P h D candidate at the University of ­Waterloo. His S S H R C -funded M A research examined the relationship between masculinities and print culture. He currently investigates nutritional policy in post-W W I I Canada.

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Index

able-bodiedness: and citizenship, 12; and health, 67–8; and the poor law, 57–8; and respectability, 41 abnormal bodies, 321–4 Aboriginal affairs: Aboriginals Protection and Restriction of the Sale of Opium Act, 78; Aboriginals Protection and Restriction of the Sale of Opium Act Amendment, 80; Aboriginal reserve system, 76, 79, 93; Aboriginal workers, 76, 81–2, 92, 94; forced removals, 78, 85. See also Cherbourg Aboriginal Settlement, Indigenous peoples abortion, 168, 185 accidents, industrial, 26, 27, 37, 41; abatement of, 35; on Boston & Worcester Railroad, 36; industrial catastrophes, 48n48; injuries and fatalities, 25–8; legal redress, 28; occupational casualties, 26–7 Addams, Jane, 231 Adjudets, 280 advertisements, 245–7; for Blackbelt, 261; for Black Label, 258; for Blackwatch Cologne, 258; for ­cigarettes, 259; for Dandricide, 259; for Dep for Men, 262–3; ­discussion of masculinity in, 252;

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for George Cologne, 258; for hygiene products, 247–9, 252, 254, 256–61; for Kent of London Cologne, 258; for Max Factor, 257; for obesity drugs, 268–95; for Preferred Stock Cologne, 254; in relation to images of sport, 248, 251–62; for Revlon, 258; for Sportsman Cologne, 255; for Teacher’s Scotch, 260; for That Man, 258. See also drug advertisements, heterosexuality, homosexuality advice literature, 247, 251, 253, 254 age, 67, 70, 87, 92 aids ac t ion now! (a a n!), 16, 202–4, 211–2, 215–6; press and media committee, 209; treatment access and research committee, 210; Treatment Information Exchange Project, 210; women in, 205–8 aids Committee to Unleash Power (act up), 201, 206, 208, 212 aids service organizations, 211–12 aids treatment: and alternative therapies, 215; clinical trials for, 202–4, 208–10, 219n11; and compassionate access to experimental drugs, 203–4; information and research

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among women, 215; women’s access to, 208. See also hiv/ aid s Alexandra Neighbourhood House Newsletter, 232 Alexandra Non-Sectarian Orphanage and Children’s Home of Vancouver, 230 Alexandra Orphanage, 230–1 American Civil War, 25 amphetamines. See drugs andrology: development of as a ­medical discipline, 153, 155, 157, 170n24, 171n30; resistance of urologists to, 157 Anyon, Keith, 192 Anyon, Margaret and Harold, 192 applicants for poor law relief, 53–4; demographic information about, 56; and health, 56; marital status of, 59–61 Atlas, Charles, 261 Ayds, 271 baby blues, 308. See also postpartum depression Bagley, Sarah, 41 barbiturates. See drugs Barnes, Gilham, 28, 36–8 Barnes v. Boston & Worcester Railroad, 37 Barthes, Roland, 248 Bartlett, Elisha, 32, 47n42 Beecher, Catharine, 33 Bevan-Brown, Maurice, The Sources of Love and Fear, 187 Biphetamine, 278, 286, 289, 290, 293 birth control, 135, 137, 138, 143, 207 Black Country, 56 Blackstone, William, 38 blame and guilt: of parents, 180, 182, 188; blame for obesity, 283, 294

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Bleakley, J.W., 80, 82–3, 85–6, 93–4 Bodies at law, 31–5 Bodies at work. See working bodies body, female: conceptualization of, 129, 131; medicalization of, 124 Boeminghaus, Hans, 157 Bordo, Susan, 245 Boston & Worcester Railroad, 28, 35, 36, 42 Bowlby, John, 187, 195 brain damage, 186, 192, 310 Braun, Virginia, 320 breast augmentation, 18, 322, 330. See also breast surgery breast surgery, 330, 332. See also breast augmentation breastfeeding, 124 Britain, 181, 186 British Medical Association, New Zealand branch report, 193–4 Buck, Pearl, The Child Who Never Grew, 194 burial expenses, 53 Caesarean section, 126, 131–2, 134, 136, 143 Cameron, David, 178 Cameron, Ivan, 178 Canadian Doctor (periodical), 268, 273, 288, 290 Canadian Medical Association, 272 Canadian Medical Association Journal, 268 Canadian Society of Plastic Surgeons, 319, 321, 326 castrates, female, 130, 136 castration, female: definition of, 135; decline in, 141; reasons for, 124, 136, 137, 140; and theory of ovarian causation of osteomalacia, 143 cerebral palsy, 178, 181, 189, 190, 192. See also children with disabilities

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Index   387

character: formation of, 101–2, 106–7, 109–10; gendered understanding of, 112–14 Cherbourg Aboriginal Settlement, 75–95. See also Aboriginal affairs Chéreau, Achille, 130 Chief Protector of Aboriginals, 78, 82 childbirth: dangers of, 124; postpartum depression and, 305, 308, 309, 311; as reason for poor law applications, 65 children with disabilities: acknowledgment of, 178; disenfranchisement as citizens, 180; impact on family life, 187–91; New Zealand context, 180–2; prenatal testing for disability, 185; stigma and ­misconceptions, 186–7, 189–90, 193–4; survival rates and care beyond parents’ lifetime, 187. See also institutionalization, parents Children’s Aid, 231 Christianity: 38, 40, 293; and American regard for compassion, 30; Christian precepts of health, 40; and early-twentieth-century Social Gospel, 231; evangelicalism and labour rhetoric, 38; ideals informing treatment of Australian Aboriginals 83; muscular, 103; and notion of character 101–2, 113; and Second Great Awakening, 30 Cilento, Raphael, 79–80, 81–3, 85, 92, 94 citizenship, 287–9, 390, 396; in the antebellum era, 25; corporeal, 25–6, 30, 38, 43; biological, 43n1, 55–6, 94, 226, 269, 296n7; body as servant to will, 25; constituent elements of, 25; definitions and ideas of post-war, 227, 228; duties of, 113; economic, 55; embodiment of, 55, 323–30; gendering and

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racializing of, 25–6; and healthfulness, 25; hygienic, 29, 32–4, 91; and manliness, 25; political, 58; training of students for, 113 colonial medicine, 76–7 Commonwealth Health Department, 79 Coney, Sandra, 246–7 congenital abnormalities, 179, 181– 2, 185–6. See also cerebral palsy, Down syndrome, Ohtahara syndrome Connell, R.W., 249, 252 conservative policies, 306, 310, 315 consumerism, masculine, 246, 251–2, 259, 262 contraception, 124, 135 Cook, Cecil, 83, 84 cosmetic surgery: current trends in, 320; ethics of, 319; female genital, 320; history of, 320, 325, 329; medical discourse on, 321, 323, 328; and the medicalization of the body 332–6; to reduce criminal ­recidivism; 327. See also Down ­syndrome, femininity Coulthard, Eileen, 186 Coulthard, Trish, 186 craniofacial surgery, 328–9 Crawford, Robert, 10, 46n26 Cuordileone, Kyle A., 249 Curtis, Josiah, 32 daycare, 307, 314 Depression after Delivery (dad), 303. See also postpartum depression, postpartum self-help movement Dexamyl, predicting side effects of, 276 Dexedrine, advertisements for, 268– 9, 275–6, 282–3, 290, 292 Dexobese, advertisements for, 277, 290

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388 Index

Diagnostic and Statistical Manual of Mental Disorders, 18, 250, 309, 394 Didrikson Zaharis, Mildred Ella “Babe”, 255–6 dinitrophenol. See drugs disability: benefits, 208; as factor driving people to apply for poor law benefits, 67; historical silence, 182–5; meanings of, 178–9; medicalization of, 178, 180; and occupational medicine, 44n5; social model of 195. See also children with disabilities diseases, rachitic, 138, 140 disorder, metabolic, 138 dispositive, 153, 163, 165 doctors. See drug advertisements, medical discourse, medical examinations, medical inspections, ­medical science Doepfmer, Rudolf, 156, 162, 176n75 Down syndrome, 179; cosmetic surgery to correct craniofacial deformities of children with, 328–9; education of children with, 181; families’ reasons for choosing institutional over home care of children with, 186–7; historical approach, 179; impact on family life, 188, 191; stigma, 186. See also institutionalization drugs: amphetamines, 271, 276, 278, 280–1, 286–7; barbiturates, 271; dinitrophenol, 271; legislation, 272– 3; limitations, 280; and men, 276, 278, 280; and pregnant women, 275, 276; safety, 295; side effects, 276–8; thalidomide, 273, 280 drug advertisements: and continuing education of doctors, 268, 270, 274–5, 292; and gender, 269; history of, 270; and partnership with doctors, 271–2, 274, 278, 281–91; and race, 282. See also humour

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Emergency Drug Release Program, 203–5 Employers’ liability and non-liability, 28, 34, 36–8, 42 Employment contract and health, 30, 42 Enlightenment, 124, 128, 129, 130 Equal Rights Amendment (er a ), 310 Eskatrol, advertisement for, 287 eugenics: agenda of Nazi regime 153, 158, 170n26; education on, 105; sterilization and 137 evangelicalism. See Christianity exercise: advice about, 100; benefits of, 31, 104, 109; compulsory in universities, 106; equipment, 10; Participaction, 269; Royal Canadian Air Force 5BX and 10BX plans, 269 factories, 26, 56; health effects of, 32; manufactories, 28 family: breakdown of traditional, 306, 310, 315; child-centred, 187; Christian-defined, 310; healthy, 187, 315; impact of ­disabled children on, 179, 182, 187–92; Maori, 191; nuclear, 85, 94, 306, 310; p ­ olitics of the, 310; structures, 54; traditional Aboriginal bonds, 91 Farley, Harriet, 42, 52n92 Farwell, Nicholas, 28, 34, 36 Farwell v. Boston & Worcester Railroad, 28, 34, 38 federation of Australian colonies, 75 Fehling, Hermann, 136–7, 143 femininity: Aboriginal, 85; ambivalence about, 135; in relation to body size, 287; and cosmetic surgery, 329–30, 332; constructions of, 209; and degenerated ovaries, 137; demonstrating “appropriate,” 237;

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Index   389

endocrinological redefinition of, 175; and marketing campaigns, 258; meaning of, 6; modelling of, 106; new forms of, 113; normative, 239; and oophorectomy, 140; as a pathological state, 124, 131, 238; and sport, 251, 256; traditional ­notions of, 245 feminism, 135, 138, 143, 304; feminist: campaign for female physicians, 142; history, 7; movement, 8, 330; and osteomalacia, 143; readers of Healthsharing, 201; scholars 309, 320; view of postpartum depression activists, 304 Fikentscher, Richard, 155–6 Foucault, Michel, 3, 16, 153, 162 free market theory, 30 free will: exerted through and over the body, 25; valorization of, 30; and workers’ right of person, 40 freeborn men. See independence Gates Starr, Ellen, 231 Gelpke, Ludwig, 139 German Medical Association, 161 German Medical Women’s Association, 161 German Society for the Study of Fertility and Sterility (d g s f s ), 155 Gerrie, J.W., 326 Giese, Hans, 159, 171n31 Gilman, Sander, 324 Glisson, Francis, 123 Gordon, Katherine, 308 Gordon, Richard, 308 Green, John O., 26, 44n9 guilt and blame of parents, 183, 188, 189, 193 gynecological surgery: and Archives of Gynaecology, 134; development of, 131, 135; German pioneer of, 125; handbook of, 132; legitimization of the need for, 124; reasons for, 126

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gynecology 124, 133, 134, 155, 158 gynecomastia, 331, 332. See also breast surgery Hall, Stuart, 248 Hamilton, James, 308 Hatterer, Lawerence, 250 hazards: of cosmetic surgery, 333; of parenting, 182; workplace, 25, 29, 34-6 Health and Welfare Canada: classification of adult Canadian patients with aids, 200 Health Protection Branch, 203–4 healthism: antecedents of 48n44; ­critique of 294; definition of 10, 46n26, 312, 322, 334; ideology of, 306; and medicalization, 336; and postpartum depression, 18, 315 healthy body: cosmetic surgery, 323; ideas in advertising, 17, 245, 247, 251, 256; of labouring men, 26; and sport, 102, 255 Hegar, Alfred, 136, 143, 149n75, 149n76 Hegarty, Ruth, 82–3, 87–8, 90, 92 Hemphill, R.E., 307–8 heterosexuality: in advertisements, 248, 250–62; defensive discourse, 241; development of “healthy,” 227, 236, 237; encouraging children’s future, 228; group belonging and, 235; and the normative male 160; promotion of 228, 235 hiv /a ids (Human Immuno­ deficiency Virus/Acquired Immuno­ deficiency Syndrome): buyers clubs, 204; case definition of, 208, 216; collective identity of women with, 212, 216; demonstrations of people with, 206–7, 209; embodied experience, 216; epidemiology, 200, 208; experimental drugs, 203-4; and gay men, 204, 206, 212, 267; and the

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390 Index

media, 200, 220n20; risk groups, 200–1, 205; and sex workers, 206; treatment activism, 205, 208–9 Hoebeke, M., 126, 131–2 Holt, Albert, 83, 88 home visits, 229, 234, 240 homosexuality, 250; and advertisements, 249, 257, 258, 260; bad parenting as cause of, 233; defined as an abnormality, 160; fears of, 246; gay liberation movement, 250; legality of, 264n15; marginalization, 251– 2; in popular culture, 247, 250; US government investigation of, 249 Honikman, Jane, 306 Hull House, 231 humanitarianism, 30, 78 humour, 252, 289 hunting, 255, 259 hysteria, 131, 135, 138, 147n41, 149n75 identity: collective, 212, 216; gender, 239, 240, 242n6; heterosexual, 241; masculine, 254, 257, 258, 261; political, 246; sexual, 227 immigrants, 200, 232 independence: of Aboriginals, 85; freeborn men, 26, 31, 41; and gender and health, 25, 33, 35, 41; masculine, 39, 59; and right of contract, 34; self-governance: 41, 85; self-reliance and health, 34, 46n31; self-sufficiency and health, 164; through labour, 57 Indigenous peoples: Australian Aboriginal, 13, 74–95; Torres Strait Islanders, 75, 78, 82. See also Aboriginal affairs industrial capitalism, 26, 35, 39–40, 102 industrialists, 31, 32 industrialization, 25, 27–30; mechanization of work, 28; metropolitan,

26559_Penny_Light.indd 390

28; proletarianization, 26–9; protoindustrialization, 127 inequities, 30, 304, 306, 315 infant mortality, 92, 129 infanticide: media representations of, 303, 311; rate of, 304 insemination: emergence of technologies, 153; controversial nature of, 159; history of, 161–2; 164–5, 167n5, 175n61, 175n64, 201 institutionalization, 188; of Aboriginals, 78, 79; Aitken Report, 192–3; of disabled child, changing attitudes toward, 186–7; of disabled child and choice of Maori parents for, 191; of disabled child, father’s attitude toward, 180, 195; of disabled child and mother’s ill health or depression, 194; of disabled child, reactions of parents, 182–6 ; and medical profession, 189, 192; ill health of male breadwinners and, 54; separation of disabled children from adults in mental hospitals, 181 Intellectually Handicapped Children Parents’ Association (ihc pa ), 192–4 International Working Group on Women and a ids, 207 Iodobesin, 293 Ionamin, 278, 283, 287, 289–91 Jefferson, Thomas, 39 Kehrer, Ferdinand Adolf, 137 Kefauver, Estes, 277 Kilian, Hermann Friedrich, 125–6, 129–32 King, Frederic Truby, 181 Kingston, Anne, 314 Kinsey, Alfred, 247; appearances in popular culture, 253; influence of work 247, 257; Sexual Behavior

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Index   391

in the Human Female, 253; Sexual Behaviour in the Human Male, 250 kinship, 86, 188 Klosterhalfen, Herbert, 157 Krajewska, Theodora, 142, 143 Kudlick, Catherine, 178 labourers. See workers Lamb, Michael, 190 Lasègue, Ernest-Charles, 132 Latzko, Wilhelm, 140, 141 laws of health and hygiene, 29, 31–5, 42 Le Dain Commission, 276 lesbian and gay liberation movement, 209 leisure, 232 Levin Farm, New Zealand, 182, 192 liposuction, 333–5 Litzmann, Carl Conrad Theodor, 133–4 Lowell Female Labor Reform Association, 41 Lowell, Massachusetts, 29, 32, 40 Luther, Seth, 38–40 McCarthyism, 250, 264n20. See also homosexuality McCready, Benjamin W., 31–3, 39 McPhail, Deborah, 287 male breadwinner ideal, 58–9, 65, 69 manliness: and citizenship, 25; masculine sovereignty, 41; middle-class conceptions of, 51 manufacturing in Massachusetts, 27; rate of business incorporation (antebellum era), 28 Maori, 180–1, 191 marketing, 225, 252, 254, 257–261, 295. See also advertisements, drug advertisements marketplace, 35; advertising in, 259; ethos of, 30; labour supply and demand, 30

26559_Penny_Light.indd 391

marital status: and gender, 59, 61–7; and health, 61–7; of poor law applicants, 56; and poverty, 59 masculinity, 229, 223, 257, 258; Aboriginal, 84; and advertising, 247, 252; and the athlete, 247; and citizenship, 55, 58; effects of whitecollar work on, 103; in relation to the frontier, 255, 259; health as a component of, 55; hegemonic, 249, 251; idealization of, 246; and male breadwinner ideal, 59; normative, 159; patriarchal control, 326; prescriptions for healthy, 226; and safer sex education, 209; training in, 238 mastectomy, 331. See also breast surgery masturbation, 130, 163, 176n76 maternal ideal, 309, 310 maternalism, 135, 137 medical discourse: colonial, 77, 128; on cosmetic surgery, 321, 323, 326; on distress after childbirth, 305; on osteomalacia, 125, 128, 135, 138; on pregnancy as women’s “normal state,” 129; and “tensions of empire,” 76 medical examinations: for Aboriginal people, 81, 84, 88; for infertility, 164; for university students, 100, 103, 104-6, 115n1 medical inspections, 81, 83–86 medical relief: club, 53; and disenfranchisement, 76; and poor law, 56, 58–9, 65–6, 68; from relatives, 69 Medical Relief Disqualification Removal Act, 58–9, 68 medical science, 322, 323 medicalization: and civilization, 83, 86, 94; and cosmetic surgery, 332– 6; of disability, 178, 180; evolution since the 1970s, 320; of men’s bodies, 159, 166; of postpartum distress, 303; of society, 292; of

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392 Index

women’s bodies, 124, 152; of women’s experiences, 304 menstruation, 88, 129, 137, 143 mental health services: connection with sexual conquest by men, 254; within the family, 187; lack of, 184; in the postpartum period, 303–5 mental hygiene: courses in, 109; definition of, 118n41, 296 Michelet, Jules, 134–5 midwifery, 133 misogyny, 124, 135, 265n29 Morand, Francois-Saveur Clément, 126, 128 nation: absence of congenital disability in visual record of, 182; future leaders of, 105; physical defence of, 107; service of, 107, 110, 114; well-being of, 310, 312, 315 National Federation of Republican Women, 310 national health insurance, 55, 70 Neo-Malthusianism, 143, 151n120 New Zealand Paediatric Society, 185 New Zealand Woman’s Weekly, 187 northeastern United States, 11–2, 25, 42 Northern Territory: Aboriginal policies of government, 78, “half-caste” institutions in, 91 Oakley, Ann, 314 Ohtahara syndrome, 178 Ontario Drug Benefit Plan, 223n58 Ontario Medical Association Bulletin, 274 oophorectomy. See castration, female osteomalacia: endemic, 139, 140, 142; etiology of, 123; hormonal ­hypothesis of, 141; male, 133; ­nutritional (deficiency) theory of, 126, 144; ovarian causation of, 134, 135–9; puerperal, 124,

26559_Penny_Light.indd 392

125–8; senile, 133; therapy of, 139, 140, 141–2; thyroid theory of, 141. See also medical discourse osteoporosis, 123, 125, 127, 132 outrelief, 57, 65 ovaries: degeneration of 137, 139, 146n38, 149n76; excision of, 135; function of, 130; “hyperactive,” 124; hyperfunction of, 137, 138, 141. See also castration, female ovarism, 129, 130 Pacific Islanders, 75 Parr, C.J., 181 Pateman, Carole, 26 patient agency, 8, 294 Patton, Cindy, 200 pelvimetry, 131, 133–4, 143 pelvis: broadness of, 124, 128; deformation of, 124, 126, 131, 133; osteomalacic, 125, 132, 134, 136 Percival, Lloyd, 269 personality: “abnormal” development of, 164; disorders, 233; educators’ discourse of, 101–2, shift to, in universities, 108–14; and postpartum depression, 313 Pett, L. Bradley, 287 pharmaceutical companies: and treatment of hiv /a ids, 202, 209; and treatment of obesity, 269–70, 272, 273–6, 292–4 physical training: in Canadian universities, 104, 106–8, 115n1; gendered nature of, 112 Playboy magazine: advertisements in, 247, 252, 254, 257, 258; advice literature in, 253; audience of, 246; Marilyn Monroe in, 245; and masculine supremacy, 252; messages about sport, 255, 259; as signifier of a lifestyle, 248, 250, 261; revenue of, 252

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Index   393

Plunket Society (Society for the Promotion of the Health of Women and Children), 181, 186 Ponderal, 276, 293 Pondimin, 276 poor law: application and report books, 56; applications in ­Stour­bridge for, 54, 56–71; ­guardians, 58, 69; historio­graphy of, 55; in Massachusetts, 35; ­outrelief, 57, 65; workhouse, 35, 55–7, 65, 68 poor relief, 35, 57, 58 Porro, Edoardo, 136 postpartum depression: causal explanations of, 312–15; concept of 307–9; increasing attention to, 305; media representations of, 303–4, 310–11; prevalence of, 311; psychiatric discourse of, 303, 304– 5, 307–9; psychiatric research on, 305–8, 311; psychiatric treatment of, 305; social problem of, 306. See also postpartum period, postpartum psychosis postpartum period: depression in, 307–9; distress during, 308–9; mental health issues in, 303–5. See also postpartum depression, postpartum psychosis postpartum psychosis, 303–5, 307–8, 311. See also postpartum depression, postpartum period postpartum self-help movement, 304. See also Depression after Delivery (da d), postpartum depression Postpartum Support International (p s i ), 303, 306. See also postpartum self-help movement, postpartum depression Pre-Sate, 277, 278, 280, 281 Preludin, 286 Prelutal, 277

26559_Penny_Light.indd 393

Probese: quantity sold, 274; contents of, 275; advertisements for, 277, 282, 287, 289, 290 procreativity, female, 128 pro-family agenda, 309, 312. See also conservative policies proletarianization, 26, 27 proto-industrialization. See industrialization psychology: rise of 101, 109; and women’s biological citizenship, 226; influence on parenting advice, 228 puerperal insanity, 307 puerperal osteomalacia. See osteomalacia queer, 230, 233, 241, 242n7 Queriot, Anne Elisabeth, 126, 128 rachitic diseases, nervous causation of, 138 Réaction Sida, 206 Reagan, Leslie, Dangerous Pregnancies, 185 reform movements: abolitionism, 30; Lowell Female Labor Reform Association, 41; self-care movement, 1970s, 46n26; Ten Hour Circular, 40; ten-hour day, 28, 38, 39 religious right, 310, 315 reproductivity, 128, 131, 141 respectability: achievement of, 41, 57; forfeiting of, 33; individual, 26, 29; markers of, 31; of a good patient 282 responsibilization, 312 rickets, 123, 126–7, 132, 140. See also osteomalacia right of person, 25, 34, 38, 40–1 rights, reproductive, 138, 212 Robertson, Jean, 193, 199n78

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394 Index

rubella, 185 Rudd, Andrea, 211–12, 215 Ruhl, Lealle, 316 Schacht, Steven, 251 Schirren, Carl, 157, 164, 176n75 Schlafly, Phyllis, 310 Second Great Awakening, 30 Settlement House Movement, 231 sexology, 157, 158, 171n31 sexual reform, 142 shame of disability, 180. See also children with disabilities Shattuck, Lemuel, 32–3, 48n44 Shaw, Lemuel, 34, 36, 48n50 Sisters of Compassion, Wellington, New Zealand, 181 skeleton: female, 124, 128, 136; male, 130; sex differentiation of, 143 slavery, 25, 30, 33, 41 Social Security Act 1938 (New Zealand), 181 social work: lack of experience among members of the Intellectually Handicapped Children’s Parents’ Association (New Zealand), 193; and h i v /a id s activism, 209; and Alexandra Neighbourhood House (Vancouver), 227–9, 231–4, 237, 239–40, 243n20 Society for the Health of Women and Children. See Plunket Society South Burnett district, 75 Special Services, 229, 233–5, 237–8, 241 sterilization, 137, 141, 159, 168 Stourbridge Poor Law Union, 56, 69. See also poor law Suffolk County Court of Common Pleas, 38 Suggestions to Expectant Mothers (n z Department of Health, 1947), 181

26559_Penny_Light.indd 394

Supiot, Mme. See Queriot, Anne Elisabeth Supreme Judicial Court of Massachusetts, 34, 38 surgery. See breast surgery, cosmetic surgery, craniofacial surgery, gynecological surgery syphilis, 64, 105, 129, 138, 156 Taylor, Darien, 211–13, 215 Taylor, Verta, 304, 306 Templeton Hospital and Farm, New Zealand, 182 ten-hour day. See reform movements Tennant, Margaret, 178, 193 Tenuate, 276, 293 textile operatives, of Lowell, 32, 40 thalidomide. See drugs Tiefer, Leonore, 320, 345 Thompson, Angela, 303 Thompson, Jeff, 303 Time magazine, 261 Tomes, Nancy, 270, 294, 320 Toynbee Hall, 231 trade unions: Trades Union of Boston, 38; Union Association of Workingmen, 39 Treatment Issues for Women living with h i v and a i d s , 213 Treatment Update/Traitement sida, 210 Treichler, Paula, 200 Trousseau, Armand, 132, 140 tuberculosis, 62, 108–9, 112, 207, 208 Turner, Jefferis, 92 United Kingdom. See Britain United Way, 230 University of British Columbia, School of Social Work, 227, 231, 232, 234, 243n20 university health programs: and citizenship, 102, 107, 111–13;

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Index   395

gendered division of labour in, 112; goal of, 100; and inspection of living conditions, 105; and mental health, 109; and psychology, 109 University of Otago, New Zealand, medical student study, 182, 184, 193 University of Toronto, 104 urology, 157–8, 170n24, 172n36, 176n76 uterus, 130, 135, 136 Vancouver Welfare Federation, 230 Verbrugge, Martha H., 29, 46n26, 46n31, 106, 112 Virchow, Rudolf, 130, 132 visual culture, 248 Voices of Positive Women, 212–17 wage earners. See workers war veterans, 159 widows, 60, 61, 68 Wilson, Leslie, 85, 92 Winckel, Franz von, 134, 140, 141 women living with hiv/ aid s : and biomedical research, 206–7, 271,

26559_Penny_Light.indd 395

273; clinical experiences of, 207– 8; gendered experiences of, 202; illness experiences of, 267, 271; symptoms of 208. See also hiv / a ids Women and a i d s Handbook, 212 Women’s Christian Temperance Union, 230 women’s health movement, 209 workday, 28, 40 workers: applying for poor law assistance, 66; as employers’ instrument, 30, 31, 41; industrial, 31; labourers, 25, 27–31, 38, 42; mill, 26, 29, 40, 52n89 working bodies, 32–3, 37, 39, 46, 56; commodification of, 33–7; contestation over, 33, 48; contracting out of, 33; embodied labour power, 37; historiography of, 32; instrumentality of, 33, 39; Labour contract and working bodies, 33; sites of lawmaking, 33 World Health Organization, 7, 14, 184 Wyden, Barbara, 250 Wyden, Peter, 250

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