• 1 See, e.g. Sharon Traweek, Beamtimes and Lifetimes: The World of High Energy Physics in Japan, Camb (...)
• 2 Erika L. Milam and Robert A. Nye, “An Introduction to Scientific Masculinities”, Osiris, no. 30, 2 (...)
• 3 Ibid., p. 3.

1In recent decades, gender perspectives have been used to illustrate that gendered practices are not only interwoven into all scientific and medical activities hitherto studied, but that the gendered ways of doing so varies with time, class, and cultural contexts. This is true also for scientific and medical contexts dominated by men, which studies of masculinity have demonstrated.1 As Erika Lorraine Milam and Robert Nye put it, men in various cultures and historical periods have constantly redesigned their “nuanced privilege” of scientific and medical masculinities in relation to “overlapping discourses of morality, family life, education, class, disciplinary affiliations, and cultural identity”.2 This has not only resulted in gendered demarcations against women, but also resulted in differentiating and segregating between groups of men, resulting in, for example, career advancement for some groups in relation to the discrimination of others.3

• 4 Kristofer Hansson and Rachel Irwin (eds.), “Introduction”, in Movement of Knowledge. Medical Human (...)

2The field of medicine has historically been dominated by men, and the field of urology still is. Even so, many men still hesitate to seek help for urological problems, at times with devastating consequences. Studies of both historical and contemporary production of masculinity within medicine can contribute to a more nuanced understanding of how power relations within medicine have been produced and reproduced, and provide material for reflection and potential change in contemporary power relations between doctors and their patients.4

• 5 This research was conducted within the project “Gender and medical simulators: Urological practice (...)

3The aim of this article is to highlight a historical case study on how such power relations were constructed by physicians active within the emerging specialty of urology in the first decades of the 20th century, as a part of the process of making urology a specialty within North American medicine. Contributing to the field of history of gender and medicine, it analyses how medical men active in this field described norms around masculinity in relation to their profession, and to urology as a field. The article argues that in so doing, they were simultaneously shaping a new version of urological masculinity.5

• 6 Steven Shapin, “‘A Scholar and a Gentleman’. The Problematic Identity of the Scientific Practition (...)

4From a theoretical standpoint, this study has been inspired by the concept of “repertoires” as it has been used by Steven Shapin. Repertoires are, in his words, defined as “relatively stable packages of attributions and evaluations”, or “ways in which very old and pervasive cultural topics are artfully re-combined and re-valued in processes of social change”.6 Shapin has used the concept as a tool to analyse the scholarly persona vis-à-vis the gentleman persona during early modernity. The concept of repertoires and attributes provides a way of framing and understanding cultural resources needed to shape this new version of urologic masculinity.

• 7 Katalin Kaproncszay, László András Magyar and Constance E. Putnam, “The Library of the Royal Societ (...)

5The empirical material comes from the Semmelweis Library and Archive of the History of Medicine in Budapest, Hungary. The library was started in the 19th century by the Royal Society of Physicians in Budapest, and became a well-equipped and modern library, serving its members with the latest medical literature, as well as organising a collection of rare books and manuscripts. A substantial part of the collections survived the World Wars, as well as later political developments, into what today is the Semmelweis Library, supported by the Hungarian Ministry of Health.7 This includes a large collection of historical urological journals, monographies, and handbooks in many languages, which makes it an excellent point of departure for exploration of the topic. From my initial gathering of some 3,000 documents (mainly in English), the texts selected for this article span from the 1890s to the 1920s and contain information about urological conditions described as related to men’s conduct, and especially such texts that contain information about urologists’ (or other medical men’s) character, behaviour, and reputation. One specific journal, the monthly The Urologic and Cutaneous Review, based in the North American town of St. Louis, Missouri, turned out to be pivotal for such discussions, and is therefore the primary source. It is complemented with articles cited or referenced therein, as well as other medical texts from the time. The material provides insights mainly into this particular site of emerging North American urological identity. Whether this kind of identity formation was representative of a larger section of practitioners of urological medicine remains to be studied.

• 8 Erika L. Milam and Robert A. Nye, “An Introduction to Scientific Masculinities”, art. cit., p. 1–1 (...)
• 9 Anne Carol, “La virilité face à la médecine”, Alain Corbin, Jean-Jacques Courtine and Georges Viga (...)
• 10 Emily Martin, “The Egg and the Sperm: How Science Has Constructed a Romance Based on Stereotypical (...)
• 11 Jennifer Evans, “Patients, Practitioners and Lodgers: Male Sexual Health Patients’ and their Heale (...)

6The historical study of masculinity in relation to medicine has combined insights from the history of science, the history of gender and medicine, and the history of men and masculinities.8 Some studies have explored a specific phenomenon such as virility, impotence, or masturbation.9 Others have scrutinised a specific medical discourse and its gendered changes over time.10 A number of studies have analysed the gendering of men as medical patients, often in relation to the medicalisation of sexuality, or in relation to specific diagnosis.11

• 12 Maria Björkman and Alma Persson, “What’s in a Gland? Sexuality, Reproduction and the Prostate in E (...)

7Previous research has shown how, in writings about the prostate (an organ defined as fundamental for a man’s physical and mental health), medical men within the emerging field of North American urology not only discussed medical procedure and treatment of the ailing gland, but were also simultaneously drawing the contours of patients’ ideal masculinity, in contrast to the vices of men with ailing prostates.12

• 13 Christopher Lawrence, “Medical Minds, Surgical Bodies”, in Christopher Lawrence and Steven Shapin (...)
• 14 Ibid., p. 194.

8Christopher Lawrence has outlined imagery culturally associated with physicians and surgeons respectively from early modernity and onwards, with a focus on the British Isles. While physicians were often presented as gentlemen, focusing on learned topics and matters purely of the mind, surgeons were associated with practical skills and manual work by the extensive use of instruments, and thus culturally connected with other occupations who used instruments on bodies, like barbers or butchers. Lawrence describes early efforts of medical specialisation from the 1750s onwards among some city-based British surgeons, who strove to change such connotations by emphasising surgery not as a practical skill, but instead as experimental science.13 Later, in the mid-19th century, both British and American surgeons had incorporated stories of “heroism” into their professional self-understanding and self-presentation, according to Lawrence.14

• 15 Elena Delia Gavrus, Men of Strong Opinions. Identity, Self-Representation, and the Performance of (...)

9In research about the development of the specialty of neurosurgery in North America and Canada, Elena Delia Gavrus depicts three generations of surgeons active in shaping the field, not only through the formal identifiers of a specialty, such as establishing procedures, societies, and journals, but also in making policies that involved the moral values of neurosurgeons as part of building a community. This even involved screening members of professional societies for certain moral qualities.15 The signifiers of both examples above are that they highlight how the surgeons themselves were active in shaping their specialties, not only through the traditional features of medical professionalisation with which we are familiar, such as professorial chairs, fixed medical degrees, and research journals, but also in shaping what could be called the “moral brand” of the specialist, be it surgery or neurosurgery.

• 16 Robert A. Nye, “Medicine and Science as Masculine Fields of Honor”, art. cit., p. 60–61.
• 17 Michael S. Kimmel, History of Men: Essays on the History of American and British Masculinities, Al (...)

10Robert A. Nye argues that physicians displaying and emphasising moral qualities and virtues are reproducing parts of a centuries-old tradition, of which the oldest parts can be traced back to the “honour codes” of antiquity. Through generations, principles of chivalry like honesty, loyalty, and solidarity have been transferred from the aristocracy into bourgeois society and inspired both formal and informal codes of conduct. In time, this also came to be true within the liberal professions.16 Even if some qualities were preserved from the honour codes of older versions of medical and noble masculinities, some were not as viable, and others were added over time. According to Michael S. Kimmel, a new ideal of masculinity emerged with the industrialisation of western societies and the institutionalisation of new financial systems, what he calls “Marketplace Manhood”. Highly dependent on the new social and financial structures, white middle-class men were now measured against their ability to succeed in the marketplace, where decisiveness, entrepreneurship, and ambition were key.17 From these examples of masculinity in relation to medical specialisation and the industrialised world of the late 19th century, it is time to turn to the empirical material, after a brief introduction to the North American medicine of the period under study.

• 18 George Weisz, Divide and Conquer. A Comparative History of Medical Specialization, Oxford, Oxford (...)
• 19 George Weisz, “Naissance de la spécialisation médicale dans le monde germanophone”, Actes de la re (...)
• 20 George Weisz, “The Emergence of Medical Specialization in the Nineteenth Century”, Bulletin of the (...)
• 21 Helen Valier, A History of Prostate Cancer. Cancer, Men and Medicine, Basingstoke, Palgrave Macmil (...)

11From the history of medical specialisation in North America, we know that the development from a tradition of general practitioners towards distinct fields of medical specialisation was a gradual process, starting with specialisation in a few areas like obstetrics and surgery in the 1850s. During the following decades, it became more common for doctors, especially in larger cities, to specialise in a certain area. The ideas of medical specialisation came from medical universities in Europe, where fixed medical degrees and research clinics were already established.18 Academic medical research demanded a great deal of observation of empirical cases within the same area, which influenced the emergence of medical specialisation. In Germany, medical specialisation flourished in the beginning of the 20th century, especially in university cities.19 However, the first period during which medical specialities became a social category was in 1830s and 1840s Paris.20 Young American doctors, trained in European medical schools where the education was organised around new laboratory disciplines, brought home the ideals of specialisation. They were supported by the American Medical Association in their aims. Medical specialisation not only helped in establishing guidelines for organising new ways teaching and practice of medicine, but also, it was argued, contributed to protecting the profession from fraudulent medicine. It also made sense in a medical world where fast-moving technical development made it difficult for the general practitioner to keep up. Thus, the process leading towards specialisation contributed significantly to redefining the role of the physician.21

• 22 Helen Valier, A History of Prostate Cancer…, op. cit., p. 57.
• 23 Ibid., p. 64.

12For urological professionalisation and specialisation, an association for genitourinary surgeons was founded in 1886. Their work was heavily concentrated on venereal diseases and their relation to urological conditions. A few years later, in 1902, the American Urological Association was founded.22 A considerable formal step forward was taken in 1933, when a board of urology was established within the American Medical Association, in order to establish educational and certification standards for urology.23 In the process of moving towards specialisation, however, some medical practitioners defined themselves as urologists at a much earlier stage, which is also reflected in the empirical material of this article.

• 24 Elin Björk, Att bota en prostata. Kastrering som behandlingsmetod för godartad prostataförstoring (...)
• 25 Sally Wilde, “See One, Do One, Modify One: Prostate Surgery in the 1930s”, Medical History, 2004, (...)
• 26 Helen Valier, A History of Prostate Cancer, op. cit., p. 57.

13The decades around 1900 were also marked by the fact that most urologic treatments were experimental in character, and varied substantially between regions and traditions, not only in the United States.24 Urologic practice continued to be a heterogenous field well into the 1930s, with few developed “gold standards” of procedure, as demonstrated by Sally Wilde in her article about how surgeons “tinkered” with their surgical methods not only in North America, but also in Britain and Australia.25 It was also a field where general practitioners still operated while struggling to keep up with the rapid expansion of advanced medical technologies available for diagnostics and surgery. The vast influx of new available technologies and surgical instruments contributed to the growing need for a urological specialty.26

• 27 Semmelweis Library (hereafter abbreviated SL): Unsigned, from the section “Syphilo-dermo Urologic (...)

15The Urologic and Cutaneous Review consistently stressed the importance of stable finances and the need for the physician to be a good businessman within the urological practice, and at times churned out brief advice like the following, from the section “Syphilo-dermo Urologic Maxims”: “A cured patient is a good asset, but nothing like a cured patient who has paid his bill.”27 Apart from such advice, the journal also emphasised other qualities, as we shall see below.

• 28 Lyman H. Butterfield, “Benjamin Rush”, Encyclopedia Britannica. Available online: https://www.brit (...)

16In the article “Advice to young physicians” from 1923, the American physician Benjamin Rush’s (1746–1813) advice to his students from 1789 was highlighted. Rush, who was a leading figure of the American Enlightenment, as well as a social reformer, politician, and teacher, contributed greatly to the North American medical education of the time and served as a professor of both medical theory and clinical practice at the University of Pennsylvania.28 Emphasised in the article was what the young doctor should strive towards, and even more so, what he should distinguish himself from. This was “advice which may well be listened to today”, the author stated, and continued with a quote from Rush:

• 31 Ludger Schwarte, “Anatomical Theatre as Experimental Space”, in Helmar Schramm, Ludger Schwarte an (...)
• 32 Elena Delia Gavrus, Men of Strong Opinions, op. cit.

19The introduction of the text introduces urology itself as a specialty that has placed itself at the very front of the “medical stage” by “shouldering” its way there after two decades. The metaphor of the stage bears some resemblance to historical reality, as surgical procedures or anatomical dissections historically were often staged in a theatrical way, with spectators allowed, in factual anatomical theatres where the patient was placed at the centre on an anatomical/surgical table, and the audience placed in tiers surrounding the procedure, or with spectators gathering in a half-circle around the surgeon, his students, and assistants.31 Metaphors from the world of acting were also used by surgeons forming the specialty of neurosurgery, as Delia Gavrus has described.32 The position at the very front of the stage, it is understood, was not reached by a given casting procedure, but by the emerging specialty’s own ability to “shoulder its way” there, indicating a competition against other medical practitioners and specialties. In the next sentence, it was established that urology not only had fought longer than any other specialty, but also that it had gained the highest respect of them all, even though no further evidence was provided in the text to back this up. The author then went on to highlight the reasons behind the high esteem and success, and shifted the focus from urology itself to the urologists:

• 35 Christopher Lawrence, “Medical Minds, Surgical Bodies”, art. cit., p. 183.
• 36 As cited in Helen Valier, A History of Prostate Cancer, op. cit., p. 57.
• 37 Helen Valier, Ibid.

22As mentioned previously, for a long time surgeons were commonly viewed as inferior to physicians, since they were involved in messy bodily practices requiring practical skills but less of a mind, and thus compared to butchers and barbers.35 Urologists had the additional disadvantage of being in close association with the causes of a large portion of urological problems—sexually transmitted diseases. According to Frank Lydston, a surgeon in Chicago, this association had made urology a “handmaiden to general surgery”, and thus was a hinderance for its independence.36 Along the same lines, in 1911, a meeting commentator at the American Urological Association stated that in order for urology to advance as a specialty, it was important to dissociate urologists from all connotations pointing to the “clap doctor”, charlatans aiming to treat venereal disease.37

• 38 SL: Unsigned, “Hypertrophy of the Prostate and Gay Attire”, The Urologic and Cutaneous Review, vol (...)

24In another account from the same journal a couple of years earlier, extravagant clothing was pointed out as not only vulgar, but also as an indicator of urological malady, namely a sign of an enlarged prostate in the middle-aged man.38 But how was a man’s choice of clothes to be a sign of prostate enlargement? To understand this, we need to unwrap some of the medical understanding of the prostate gland at the time.

• 39 SL: James H. Polkey, “Incomplete Late Results After Supra-Pubic Prostatectomy”, The Urologic and C (...)
• 40 Elin Björk, Att bota en prostata, chapter 4, p. 25–42. See also Chandak Sengoopta, The Most Secret (...)
• 41 SL: James H. Polkey, “Incomplete Late Results After Supra-Pubic Prostatectomy”, The Urologic and C (...)

25In the beginning of the 20th century, the prostate was understood to belong primarily to the sexual system, and to consist of both glandular and muscular tissue. The glandular function was believed to produce a secretion that, with help of the muscular tissue, would enable the secretion to eventually mix with the spermatozoa. Thus, the prostate was thought to play a crucial role for a man’s reproductive system. Apart from reproduction, the prostate was also believed to be part of a system of “internal secretion” that regulated many of the bodily functions.39 The idea of internal secretion belonged to a much-debated model of thought that was later replaced by insights from endocrinological research on how the hormones of the body worked.40 Via the system of internal secretion, some medical practitioners believed, the prostate had a direct connection to the brain, even though it was not known exactly how this system worked.41

• 42 The prostate could also be enlarged due to cancerous growth. Discussed in this article, however, i (...)
• 43 SL: Unsigned, “Hypertrophy of the prostate and gay attire”, art. cit., p. 251.

26Prostate enlargement was understood as a phenomenon that mainly affected men past fifty years of age and was (and still is) considered a part of the ageing process, even if it at times also could affect younger men. Neither the aetiology of the condition, nor how the process occurred was fully known, and various explanations were considered.42 Prostate enlargement, or hypertrophy, was also believed to, at times, make the man’s sexual energy increase, and lure him into behaving like a younger man. This prostate-induced increased sexual appetite, it was argued, was the reason behind the phenomenon where middle-aged men got married to much younger women, but also changed their dress and their conduct in other ways. The condition, it was stated, was characterised “by behavior that does not fall far short of being asinine, and by dress that is gay, flamboyant and offensive to the sedate and the refined”.43 The author then went on to describe how the foolish behavior could play out when the prostate caused these symptoms:

• 46 Elaine Showalter, The Female Malady? Women, Madness and English culture, 1830-1980, London, Virago (...)

28This advice illustrates the point that not even urologists were beyond the risks posed by their own bodily functions, in this case the result of a growing prostate, a part of normal ageing. Even urologists could become victims of the ill social judgement associated with the condition, and thus be targets of ridicule, or even ill-will from “enemies”, according to the quote above. Apart from such associations, the symptoms of the prostate related to a flamboyant dress code could also bring forth unwanted associations with the previous kind of urologic masculinity, from which it was so important for the urologists of the 1920s to distinguish themselves. The enlarged prostate was not merely considered an effect of the ordinary ageing process. It could also be interpreted as the result of sexual misconduct. Often in the history of medicine, it is women who have been described as victims of their bodily functions. One example is the hysteria diagnosis, where the uterus was described as the culprit for altered, inappropriate female behaviour.46 Here, the enlarged prostate played a similar role for men, via its internal secretions. However, an enlarged prostate was believed not only to affect a man’s judgement in relation to his marriage decisions or his choice of clothing, but it could also affect several other areas in life as well, as will be discussed below.

• 47 SL; George W. Overall, A Synopsis of Reprints on the treatment of Stricture, Urethritis, Prostatit (...)
• 48 SL: George M. Phillips and Forty Distinguished Authorities, ed. by S. C. Martin, Prostatic Hypertr (...)
• 49 SL: Unsigned, “The Prophylactic Value of Prostate Massage”, The Urological and Cutaneous Review, v (...)
• 50 SL: George W. Overall, A Synopsis of Reprints…, p. 24.
• 51 SL: See, e.g., articles “Human Bisexuality”, “Homosexuality and Alcohol”, “Missing Girls”, “Wander (...)

29When it comes to how an enlarged prostate could be caused by sexual misconduct, one practitioner claimed that hypertrophy of the prostate could be the effect of an inflammation of the urethra, the inflammation of the urethra in turn being the result of “grave moral vices”, like masturbation.47 Thus, in this explanation, it was a chain of habits that started the pathological process leading up to the condition. Other practitioners believed that the hypertrophied prostate could be either the result of degeneration of the gland, sometimes spurred on by sedentary work, or that it could be caused by “sexual excess”.48 But how were “moral vices” and “sexual excess” characterised, apart from masturbation? Excessive, i.e. too much sex belonged there, as well as withdrawal during intercourse.49 Sex outside wedlock also belonged to the vices,50 as did bisexuality, homosexuality, and transvestism, even if they were not particularly discussed in relation to the healthy or unhealthy prostate.51

• 52 SL: From the section “Syphilo-dermo urologic maxims”, art. cit., p. 67.

31Another poignant example of the same perceived need for distancing from this patient group can be found in the journal section “Syphilo-dermo Urologic Maxims” in January of 1923, where the urologist was, in a laconic fashion, advised: “Suffer no familiarity on the part of venereal patients.”52 Some practitioners even claimed that urology had gone too far in their distancing from this area. In a text about “The Urologist and Sexual Diseases”, the author states:

• 54 SL: James H. Polkey, “Incomplete Late Results After Supra-Pubic Prostatectomy”, The Urologic and C (...)
• 55 Helen Valier, A History of Prostate Cancer, op. cit., p. 73, p. 77, p. 82.

33Apart from the high risk of being “contaminated” by this patient group, the urologist affected by a prostate ailment also risked other areas in his life being affected, like his mental health and intellectual capacities. This was explained partly by the idea of internal secretion, but also by the understanding that an enlarged prostate often carried an infection, and that the infection produced toxins that affected the nervous system, with negative effects on the brain. Expressions of such effects could be hypochondria, hallucinations, melancholia, depression, and in severe cases even suicidal tendencies. To the less severe symptoms belonged memory loss, lack of concentration, irritability, and sometimes insomnia.54 According to Helen Valier, the idea of mental conditions as an effect of prostate disease continued to exist even in the 1930s.55 Thus, physicians and surgeons within the emerging specialty of urology who suffered from a misbehaving prostate would be at risk of having a compromised intellectual capacity, making it hard to earn trust among colleagues, as well as to function as a practitioner and a representative of the community of urologists in the emerging specialty.

• 56 Christopher Lawrence, “Medical Minds, Surgical Bodies”, art. cit., p. 188.

36The strategy these urologists applied is similar in one respect to the strategies used by general surgeons, as described by Christopher Lawrence. When general surgeons in the late 18th century strived to refashion the way surgeons were regarded, they did so by describing themselves with attributes borrowed from the repertoire of the scholar/physician, thus associating themselves and their profession with learning and science, instead of visceral, messy operations. They also presented surgery as an occupation fit for gentlemen.56

• 57 Steven Shapin, “‘A Scholar and a Gentleman’”, art. cit., p. 279–327, p. 312–313.

37In his analysis of the development of American masculinities of the 1900s, Michael Kimmel argues that white middle-class men in the industrialised world had to adjust to a new marker of success, namely financial success. This affected the medical arena of the time as well. Taking on some characteristics of a businessman was therefore important. Qualities like salesmanship, a watchful eye for opportunity, and the ability to shoulder forward, sometimes at the expense of others, were thus needed for the successful urologist of the 1920s, even if such attributes in other times had certainly not been regarded as gentleman-like. In this way, the borrowing of attributes from businessmen is more in line with what Shapin has described for scholars and men of science who, in the 18th century, associated themselves with the mercantile and merchant classes of bourgeois society and legitimised their occupation with utilitarian motives.57