Hysteria, Hysterectomies, and Clitoridectomies: Not All Surgeries are Equal in Insanity

• Why was it that clitoridectomies, hysterectomies, and ovariectiomies were preformed as treatment for mental illness in the 19th century?

• Why did each surgery draw different levels of scrutiny from the medical community at the time?

• Why did some surgeons see successful results and how is this informed through modern medical discoveries?

In the highly experimental age of nineteenth century medicine, rapid development of technique and theory was a path laden with the bones of the disenfranchised. The poor, the othered, and the mentally ill were sometimes sacrificed in the name of medical development. One particular field where abuse of patients in the name of scientific stardom for doctors was women’s mental health. Altruistic and opportunistic doctors alike found it easy to experiment on women, who typically lacked agency to argue for their own health needs. With such a "loose leash" on doctors developing cures and little legal recourse when research became unethical, how and why were these experimental cases blocked? To understand the values of the nineteenth century mental health medical profession, one must explore how some of these gynecological surgeries were admonished versus how others were permitted. From a more contemporary standpoint the removal of the clitoris, ovaries, or uterus for reasons not distinctly gynecological seems equally violent and anti woman, however the 19th century medical community decided not all surgeries are created equal. Why is it that Dr. Isaac Baker Brown was disbarred and sent into metaphorical exile for his work with gynecological surgeries to fix mentally ill women, while just a few decades later Dr. R.M. Bucke was given a platform for discussing seemingly similar methods? 

Three major factors present as chief when dissecting the works left behind from these old medical societies and their research. Firstly, there is a historical precedent left behind and past assumptions many medical professionals worked from when developing cures for mental illness. The idea that the womb specifically was linked to women’s insanity played a huge role in this factor. Secondly, the difference in execution and optics of the surgeries influenced a surgical method’s acceptance in the medical community. While abuse of patients and botched experimentation was rampant in the nineteenth century medical field, even a corrupt machine such as medical societies will turn against their own when violation goes too far. Finally, the third reason why some surgeries were enabled was because in certain instances illness was assuaged. Though many surgeons did not have the modern medical know-how to understand why removing ovaries made a woman not scream endlessly for hours upon hours, their efforts were successful in a way that can be explained through modern medical research. 

Historical Precedent’s Effect

A person does not need to be an expert on the history of mental health to recognise the similarities in the nomenclature for the words “hysteria” and “hysterectomy.” The uterus was as toxic as it was life bringing in the eyes of medical professionals for a multitude of centuries. In the era of miasma theory each humor had a specific level that had to be maintained, every bodily secretion indicated one thing or the other about a body. The book On Hysteria: The Invention of a Medical Category by Sabine Arnaud describes a work published in 1761, one of the first times menstruation is mentioned in any medical publication, “According to physicians, menstrual blood was a noxious substance that could have various effects on bystanders, or even on objects such as mirrors. It could sour milk and wine, make plants infertile, sicken dogs, and kill flies.” This published work, Traité des maladies des femmes (Treatise on Women’s Illnesses), goes on to explain that semen is the only way to assuage the toxins that would otherwise penetrate the mind, causing insanity. The womb was a necessary evil in human form. It would sponge up a woman’s lifeforce, but at the same time it is what gave her purpose as a bringer of children. 

As the field of mental health grew to be a study accepted by the scientific community, a vocabulary began to be established. Melancholia, anorexia nervosa, and neurasthenia all became terms to describe mentally ill people. Hysteria as an official diagnosis became present in the nineteenth century, scholars citing Jean-Baptiste Louyer-Villermay’s in depth description of an intertwined set of criteria that he believed could define the malady. For about 50 pages Louyer-Villermay synonymizes the disease with a failed womb.  Sabine describes that “He justified his selection of the term “hysteria” as follows: ‘It expresses the idea attached to it quite well, and . . . use has consecrated it.’ The noun was read as metonym, functioning as proof that the origin of the illness was in the womb.” Using the term to generalize any of women’s mental health issues was not entirely new, however, hysteria had been used in the medical sphere since at least 1801 by Marie-Joachim Vigarous and Philippe Pinel, both respected medical professors in Montpellier and Paris respectively. Unofficial rhetoric of hysterical women had been used for far longer yet, with its origins being derived from Greco-Roman theories of a woman's emotionality relating to the violent movement of the womb. 

Even from a non-mental health standpoint the uterus was the most medically researched piece of uniquely female anatomy. In contrast, for example, the clitoris was considered a hasty footnote, and the ovaries were mysterious orbs. In 1543 De Humani Corporis Fabrica (On the Fabric of the Human Body) was published by Andreas Vesalius. This series of medical books was revolutionary in form, as it offered some of the most detailed illustrations of the human body, paired with informative descriptions. Chapter fifteen of book five titled “On the Uterus and Other Female Organs Serving Reproduction” dedicates nine pages to female organs (seventeen in the updated 1555 edition). Most diagrams and subsections were focused on the uterus, and a few were dedicated to “the testicles of women,” now known at the ovaries. Notable in this chapter is how its title claims its focus is strictly on women’s reproductive organs, as the clitoris is nonessential to reproduction many medical practitioners neglected researching the organ. Thus, the medical community’s blatant state of ignorance around the clitoris continued off and on for centuries. A few outliers in the community emerged, Regnier de Graff, for example, wrote on the organ’s structure and possible function in his 1672 book Treatise on the Generative Organs of Women. Eventually in 1844 George Ludwig Kobelt presented his analysis of what the function of the clitoris is. The article “Clitoral Anatomy: A Comprehensive Scientific Review” writes “His account of female sexual anatomy is extremely comprehensive. He performed dissection, comparative anatomy and injection studies, the latter to simulate sexual arousal.” Finally, in the nineteenth century scientists had not only established the presence of the clitoris, but also that purpose was outside of being strictly reproductive, being related to arousal and pleasure rather than essential to the creation of children.

From this variance in research depth between the ovaries, uterus, and clitoris one can see a trend in which surgery is preferred for “curing insanity.” To start, there is the previously mentioned idea that the womb held the toxicity that fed women’s insanity. Though miasma theory was falling out of style, deviating from a set of beliefs held since the Greco-Roman era is not something easily unlearned. Building off of previous theories was far easier than trying to swim against the current, creating opposing theories. For example, in 1836 Robert Brudenell Carter quotes Dr Theophilus Thompson’s in his book “On the Pathology and Treatment of Hysteria,” “‘The principal views which have been since entertained by authors, may be arranged as follows:—1. Hysteria has been referred to as a morbid condition of the uterine nerves by Bullen, Pinel, Lieutaud, Louyer-Villermay, and Foville.” While Carter later elaborates on how he has a contrasting view to what the leading scientists believe the connection between hysteria and the uterus is (namely that he believes that men can also be hysterical and mainly choose not to be, making the phenomenon more voluntary then due to a flawed uterus) he recognizes the theory that many of his peers cling to. Most all the theories he mentions and critiques have something to do with the uterus or ovaries. There is clear history to the idea that hysteria comes from the womb and with that history comes a normalization of treatment. If it is a leading theory that the womb is the cause of insanity, then it is normalized that the removal of said organ occurs.

On the other hand, mentions of the newly realized clitoris remain absent. While writing frequently on the uterus’s role in hysteria and writing once on ovaries, Carter does not indicate any acknowledgement of the clitoris’s existence, let alone its role in hysteria. In his book Clinical Observations on Functional Nervous Disorders, not once does C. Handfield Jones indicate any connection between insanity and the clitoris either. Nor does the man that coined the term “hysteria,” Louyer-Villermay, ever explore the clitoris either. The newly “discovered” organ had just had its function realized, so its place in hysteria’s rhetoric was on the fringes of discussion. At this point its role in causing insanity was being limited largely to speculation and racist rhetoric. Due to the lack of reproductive value clitorises had, the narrative pushed by many individuals in the scientific community was that use of clitorises, particularly “engorged clitorises,” was a hallmark of the “lessers.” In the article “I Always Prefer the Scissors” by Marjorie Levine-Clark she describes this phenomenon, “She argues that a prominent or enlarged clitoris had become a common marker to the Victorian medical community of blackness and criminality — observed in African ‘Hottentot’ women as well as British prostitutes— and was, therefore dangerous,” as does “Clitoral Anatomy: A Comprehensive Scientific Review”:

“He believed that this was ‘an unusual feature that occurred in almost all Egyptian women’ as well as ‘some of ours, so that when they find themselves in the company of other women or their clothes rub them while they walk or their husbands wish to approach them, it erects like a male penis and indeed they use it to play with other women, as their husbands would do....Thus the parts are cut off as is described in Aetius [an early 6th century Greek writer] and others.”

These aforementioned groups were often strategically labeled insane, sometimes truthfully due to the devastating impact of syphilis on sex workers in Britain, but sometimes these claims were simply falsehoods used to diminish and other those deemed undesirable. This school thought that diseases of the clitoris cause insanity, however were largely more fringe in nature. The idea was newer and based on a smaller group of individuals that were not prioritized due to their impoverished status. All in all, scientists were largely focused on the uterus and ovaries as insanity causers, leading to a greater normalization of their removal than the clitoris. 

Surgical Practices

While historic theories contributed to what surgeries psychosurgeons performed, a major factor in the field’s acceptance of a surgery’s validity is the ethics and optics involved in patient treatment. Human experimentation has been ingrained in the development of every surgical technique. In gynecology in particular, many women have often been unwillingly put under the knife to prove or disprove the validity of a technique. Sacrifices must be made for the development of each cure, however, how does the surgical community decide if the procedure is uniquely ‘gory,’ ‘violent,’ or ‘unnecessary?’ The contrasting opinions on clitoridectomies, hysterectomies, and ovariectomies in the mental-surgical field can be attributed to the willingness of the patients, the aftereffects of the surgeries, and the visual markers distinguishing the surgeries.

Clitoridectomies

To begin one can examine the proprietor of the clitoridectomy as treatment for insanity: Dr. Isaac Baker Brown. Brown was a well respected gynecologist in Britain, boasting a multitude of titles and accolades mentioned in his book On the Curability of Certain Forms of Insanity, Epilepsy, Catalepsy, and Hysteria in Females including “Senior Surgeon to the London Surgical Home,” "President of the Medical Society of London,” and eleven more named designations. The surgeon was at the forefront of the field of gynecology and praised for his work on ovarian dropsy and vesico-vaginal fistula, however when he published On the Curability in 1866 he received major backlash. He began his work by referencing research by Dr. Charles Edouard Brown-Séquard. Brown-Séquard’s research that inspired Brown’s exploration of clitoridectomies discusses a variety of different experimental cures that include removing “diseased bone” from the cranium, increasing a patient’s iron intake, and the method that inspired Brown, the "ablation of the clitoris.” While Brown-Séquard’s method called for the more mild chilling of the clitoris to reduce irritation to cauterization, Brown made his “improvements” on the concept by doing surgical removal of the organ with scissors. In Brown’s previously mentioned book he describes his success with the procedure, but even then, his proud veneer demonstrates blemishes. He discusses a specific case of a woman who was afflicted with unspecified mental illness for twenty years and allegedly immediately showed positive results “the result of the operation was most marked; the irritation subsided, the patient improved in health, and we confidently expected permanent relief.” When symptoms returned, however, he promptly blamed the family of the woman for not giving the patients adequate rest as he prescribed. Every success was a result of his actions, and every failure was a result of others.

Later that year a dialogue of scathing critiques a dialogue of scathing critiques flooded the pages of The British Medical Journal. Starting on November 24, 1866, a concerned medical professional, Dr. West, raised questions of the morality and abuse involved in the procedure. West begins by challenging the relevancy of masturbation as a trigger towards insanity, and acquiesces that though masturbation is immoral, a lack of evidence remains about if the procedure even works. His most damning critique of Brown’s procedure was as follows:

“I believe that few members of the medical profession will dissent from the opinion that the removal of the clitoris without the cognisance of the patient and her friends, without full explanation of the nature of the proceeding, and without the concurrence

of some other practitioner selected by the patient or her friends, is in the highest degree improper, and calls for the strongest reprobation”

This implication of a lack of consent in the procedure, an element of foul play, was a heavy accusation. In the December 15th edition of the same journal, it is discussed that the Obstetrical Society of London approached the topic of the surgery and they unequivocally decided that it was a procedure of needless violence. The only ways that they foresaw the supposed hysteria being ended was on a temporary basis due to “the mere shock and mental impression.” December 22 saw more letters from medical professionals including one that mentions how the procedure was suggested to be executed on a little girl the age of seven. Another key point was with the idea that masturbation was not the causation, but the byproduct of insanity with Forres Winslow, for example, saying, “the source of the disturbance is, in the majority of cases, situated in the head; and that Mr. Baker Brown begins his treatment of these cases at the wrong end.” A letter by Brown was also published in this journal, however his writing does little to refute claims of women being operated on ill informally, opting to instead defend the success of his surgery. December 29th saw clitoridectomies being discussed once again, another doctor claimed his patient received a botched result that led to melancholia. Brown makes a final response to these allegations January 5, 1867 with outcries of gross verbal slander, "more violent animosity is exhibited towards me than any gentleman would think possible for one professional man to entertain against a mother practitioner.” He tries to refute previous claims against him, however once again he mainly focuses on proving his results, rather than addressing his abuses. 

Soon after this exchange Brown was removed from the Obstetrical Society of London and his name would forever be tied to one of the most sensational surgeries performed on the mentally ill in the name of cures. Through a combination of suspicious surgical practice and a lack of results Brown turned the entirety of British surgical society against him and his “harmless procedure.” How does the violence and public perception of the clitoridectomy compare to that of the ovariectomy and the hysterectomy for mental health cures? To explore this phenomenon, one must look about thirty years later and a sea away.

Hysterectomies and Ovariectomies

On May 10th, 1898, Dr. Richard Maurice Bucke gave his Presidential Address to the American Medico-Psychological Association in St. Louis. Though a man of philosophy and poetry, Bucke’s primary focus was in mental asylums and surgeries to benefit the insane. He begins his address by talking about cases he explored and operated on as well as ones his colleagues performed. From the beginning there are stark differences between On the Curability by Brown and the address titled “Surgery Among the Insane in Canada” by Bucke. The tonal contrast between the two works is very evident, Bucke approaches with a less hostile stance. Instead of demanding the morality of the surgeries, he suggests listeners keep an open mind. This does however highlight similarities between the perception of Brown’s and Bucke’s surgeries, there was a greater moral and emotional disagreement that some scientists carried towards these procedures, however one had more critiques than the other. In an article by Wendy Mitchinson called “Gynecological Operations on Insane Women: London Ontario. 1895-190” Mitchinson details Dr. Bucke and his colleague Dr. Hobbs’s motivations and reasoning about their surgical techniques, but also the surgical field’s reactions to the procedures. Mitchinson mentions how it was a widely believed theory that the uterus was the cause of hysteria, but new research made ovaries seem to be the culprit. Either way many scientists thought the sexual organs were to blame for insanity. She goes on to mention how there was a split between what factors of the research and experimentation Bucke did were applauded or lauded amongst scientists. Oftentimes a factor seen as negative by one scientist would be positive through another’s view, in contrast to how the British medical community almost unanimously saw Brown’s work as grossly abusive. Many similar arguments were made against Bucke’s surgery to Browns such as that [the patients] could not give consent” and that a lot of conservative rhetoric about the conservatism around acknowledging female sexual organs in any way, often to protect a woman’s modesty that she may perish without.

Another reason why Bucke’s argument was more successful was that he presented his work in a more palatable way than Brown through offering a survey of his peers. The purpose of this survey was to encourage the government to build an infirmary to make the frequency of these surgeries greater. The address claimed:

“2 Opposed the work,

3 Were Non-committal,

10 Expressed moderate approval, 

35 Expressed strong approval, while

205 Expressed very strong approval and said it was the duty of the asylum staff to carry on the work”

Bucke then proceeded to mention twelve positive comments offered by survey takers about the procedure. This survey helped present to the “nae sayers” how there is a large percentage of staff that have intimately seen the procedure and agree with it. Bucke writes, “if we find a widespread, almost universal belief of this kind in the mind of the general profession, we should not be wise to conclude that it is unfounded until we have taken pains to satisfy ourselves of the truth or untruth of it.” Bucke’s openness towards the existence of those who disagree with the procedure as well as framing the procedure as not being the isolated concept of a single man seemed to greatly benefit his case. On the other hand, Brown’s research only mentioned the surgeries he performed and their results, outside of the infrequent name drop of Dr.  Brown-Séquard.

From this contrast between Brown and Bucke, one can see a defined difference between public perceptions of the two men’s procedures they advocated for. Much of the acceptance was derived from presentation, transparency, and the perceived violence of each procedure. Bucke offered peer reviewed research with references to other scientists' approval of the surgeries. Brown, on the other hand, chose to emphasize his own ingenuity and how he was the only one performing these operations, which led to the field doubting his results. Another aspect that kept the public from turning against Bucke was how there were no allegations of him operating on underage girls, something that could not be said about Brown. Observing all this there is validity in the statement that though both men did have critics, Brown’s opponents far outnumbered the more divided camp Bucke experienced in the North American field.

Scientific Merit

While “facts” established by past concepts of hysteria and the optics of violence surgeries both have a large role in if the field will accept a surgery, at the end of the day a procedure’s efficacy presents a strong argument for or against a surgery. Previously discussed is how Brown’s surgeries yielded a lack of results, though Bucke is believed to have exaggerated his results, his results did come. Why was that? How does this also tie into the situation of optics for the surgical community?

Something that creates a defined difference between the procedures of Brown and Bucke is the sign of physical disease on the organs they operated on. Brown mentions physical signs of needing a clitoridectomy only once. What he describes sounds like a normal clitoris, but larger than what he sees as typical. He writes on “Case XLVII” that “the clitoris was enlarged and hard.” Seemingly, the only physical, “scientific” aspect that encouraged him to remove the clitoris was masturbation habits of the patient, which he believed was causation and not coincidence in regarding their illness. In contrast when Bucke and his colleagues removed their patients’ uteruses and ovaries they frequently were removing cysts, lacerations, cancers, and generally diseased sex organs. He offers statistics based on these surgeries:

“1. Hysterectomies, 16.

2. Removal of diseased ovaries and tubes, 12.

3. Operations for replacing and retaining uterus in normal position, 22.

4. Operations on cervix, 30.

5, Operations for minor uterine diseases, 21.

6. Operations for vaginal lesions, ect., 8.”

He proceeds to surmise that ovaries, cervix, and endometrium’s health is almost important for a woman’s mental wellbeing. Bucke describes that he believes the answer of why these organs cause insanity lies in “internal secretions” and compares the emissions to other secretions by testicles. What is the significance of this assertion, however? Unlike Brown who is asserting his claims from what symptoms are, Bucke is attempting to present scientific backing from recent medical discoveries, in this case referencing a newly published textbook from 1896. These secretions he is referring to can likely be understood as hormones, which does affect mood in many ways.

With the understanding granted by modern science is there any merit to Bucke’s claims? First, it is important to establish that Bucke’s claims are likely highly exaggerated. Like many of these scientists with experimental cures they unknowingly exaggerate the efficacy of their cures with confirmation bias, or they more likely make their claims seem real through doctored statistics. Mitchinson comments on her doubts about Bucke’s research writing, “Acceptance of the link between a woman's reproductive system and her mental health, which had been partially reinforced by popular attitudes towards women's emotional nature, encouraged Bucke in the internal examination of his patients…. This linkage was then used to justify the examination procedure, and it prompted Bucke and Hobbs to exaggerate the incidence of disease in female insane patients.” She also comments on how Bucke began already convinced that his idea was true, choosing to work backwards from his theory and pick and choose to assemble evidence afterwards. 

Understanding that Bucke’s research must be taken with a grain of salt, it can now be acknowledged that by coincidence Bucke’s surgeries may draw results in select cases. The first possible case can be referenced in the previously mentioned article “Hysteria, Hysterectomy, and Anti-NMDA Receptor Encephalitis: A Modern Perspective on an Infamous Chapter in Medicine” by Thomas A. Pollak. This article identifies how female patients with anti-NMDA Receptor Encephalitis have strikingly similar traits to what described of women in these mental asylums that were “fixed” by having their ovaries removed. Pollak writes, “Up to 60% of cases of anti-NMDA receptor encephalitis in adult females may be associated with the presence of an ovarian teratoma; removal is recommended and is associated with improved outcome.” What is anti-NMDA receptor encephalitis, however? This disease is extremely rare, with one in 1.5 million people being affected by it per year. Females are four times more likely to have the disease than males, with women twenty-five to thirty-five most affected. The disease has a laundry list of different symptoms including depression, eating disorders, muscle rigidity, hypersexuality, seizures, and mutism. The teratoma-associated variant of the disease mentioned by Pollak emanates from the ovaries teratoma and how they react with neuronal cell surface auto antigens. Treatment for this disease calls for the removal of the ovaries, with women greatly improving with said removal. Therefore, some of Bucke’s alleged success may have been on patients that suffer from this disease.

The second modern medical example that might have led to a diagnosis or surgery by Bucke is PCOS, or Polycystic Ovary Syndrome. PCOS is far more common than anti-NMDA Receptor Encephalitis, with an estimated 6-13% of women of reproductive age having it. The disease has physical symptoms such as unpredictable and abnormal periods, weight gain, male pattern baldness, and excessive body and facial hair. As for mental symptoms, “The prevalence of anxiety and depressive disorders among women with PCOS ranges from 28% to 39% for anxiety and 11% to 25% for depression.” The disease’s cause is unknown, but it is known to be affected by a variety of unbalanced hormones from the ovaries. Modern treatments can be found through birth control and natural remedies such as exercise. An ovariectomy is not a cure to the disease as can sometimes be found with Anti-NMDA Receptor Encephalitis, however it can be used as a last-ditch effort for removing the androgen hormones that aggravate the procedure. Unfortunately, side effects from the procedure can often outweigh the benefits, and with non-invasive treatments the surgery is not often performed in the modern day, however without access to birth control or other treatments to assuage PCOS’s symptoms ovariectomies might have offered some reprieve from suffering.

These modern examples of Anti-NMDA receptor encephalitis and PCOS suggest that Bucke may have benefitted the mental health of select women with his surgeries, despite his misunderstanding of why the surgeries were successful. Though his success is likely exaggerated, a kernel of truth remains in modern diagnosis and treatments for PCOS and Anti-NMDA Receptor Encephalitis. This proof of actual success, that contrasts the unsubstantiated claims of Brown, likely contributed to the acceptance of hysterectomies and ovariectomies over clitoridectomies as a plausible treatment for mental illness. Thus, it was through a combination of historical precedent, optics of the surgeries to the medical societies, and actual success of these surgeries, a different understanding and acceptance was established between hysterectomies, clitoridectomies, and ovariectomies as surgeries for mentally ill women.

I would like to acknowledge the advice and support provided to me by my honors history professors Dr. Schakenbach Regele and Dr. McVety. Their aid guided me on my research and benefitted my finished product. I would also like to thank my good friend Hope for providing me with numerous edits and great emotional support throughout my research ordeal.

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