Cosmetic Surgery has an ancient pedigree but becomes a global social force through developments in modern surgery at the close of the 19^th century. Ancient surgeons, from the Egyptian Edwin Smith papyrus urging surgeons to avoid disfigurement in setting a clavicle fracture through Galen’s desire for ‘beautiful sutures,’ were quick to recognize that the less obtrusive the scarring, the better the result, at least from the standpoint of the patient [1].

Appearance mattered to the surgeon and the line between not scarring the patient and providing for relief from disfigurement (however understood) was never quite clear. As Roy Porter noted the charge of quackery is lodged against cosmetic practitioners beginning in the 18^th century:

Appearance was of vital importance in the face-to-face encounters of early modern society not least because so many people were born somewhat deformed, or had become unsightly through smallpox, skin disease, eye complains, accidents, and suchlike. Not surprisingly, therefore, cosmetic medicine loomed large in the promotions of the quacks and the minds of their customers. Radical cures were, naturally, part of the rhetoric; but many quack bills also laid great stress upon their capacity to patch people up effectively, removing growths, sores, scabs, and ulcers [2].

This ‘quackery’ was, however, not very much different in its approach and success from the procedures developed and used by physicians within the medical establishment of the time.  The label ‘quack’ was used to limit the investiture of those permitted to undertake ‘serious’ interventions. In the eighteenth century, the Edinburgh ‘quack’ John Taylor, a surgeon trained at St. Thomas’ Hospital in London, according to his own account, removed scar tissue from the lower lid of a burn victim’s eye (Fig. 1). The pain was excruciating in this age before anesthetic, but the physician continued, beauty as his and his patient’s goal:

Fig. 1: Portrait of John Taylor. National Library of Medicine, Bethesda, Maryland.

I immediately passed a needle through the skin of the temple, near the lesser angle of the eye, and with my lancet dissected, to about half an inch diameter, the skin of that part from the muscles. Whilst thus employed, her excellency often called out to me, ‘you hurt me! you hurt me!’ And I as often answered ‘remember lady, beauty! beauty!’ and with this charming word beauty I softened her pain in such a manner that she kept her courage to the end of the operation, which was to draw the edges of the wound together and fix them so by passing the needle threaded through them as to tie them together.  Thus, I brought that upper eyelid into its place without touching it, and after putting on the wound now closed, a small plaster, which seemed rather an ornament than a blemish, I conducted the lady back to the courtiers in the palace. Seeing her thus changed, they all appeared astonished, and looked as if this business had been done by some miracle [3].

Taylor performed a number of cosmetic procedures, including removing part of the upper eyelid in a patient who suffered from a drooping eyelid (ptosis), using a procedure, which would become common place a hundred years later. Despite his evident skill, Taylor was a ‘quack’ according to the Edinburgh Royal College of Physicians, which excoriated him in print. And this was to no little degree because his stated goal in his account was ‘beauty [4].

For ‘beauty doctors,’ as William Hogarth at shown in his ‘Marriage a la Mode,’ offered the means of masking illnesses as well as restoring beauty (Fig. 2). In the opening plate ‘The Inspection’ we see a couple visiting a well-fed and pompous ‘quack.’ There is a dark circular patch on the neck of Viscount Squanderland, likely a deliberate ‘beauty mark’ of velvet concealing a syphilitic scar, or a tuberculous scrofula, serving for the view of this scene in the doctor’s office as an indication of disease [1]. Indeed, how are we to distinguish this from Taylor’s ‘a small plaster, which seemed rather an ornament than a blemish.’ ‘His mistress, frail and wan, dabs her mouth, perhaps a sign of distress or of impending illness? The woman between the doctor and the Viscount, also ridden with dark beauty spots, is being offered a mercury pill to cure her syphilis. The doctors, quacks or not, provided the means by which diseased faces could pass as healthy. They offered cosmetic interventions of the sort we today associate with beauty salons and well as therapeutics, including, in the case of some, surgical interventions. ‘Natural’ beauty, created by the physicians, was a guarantee of the health of the individual as well as the health of the state. But Hogarth knows better for in the final plate The Lady’s Death, Mrs. Squanderland is on her deathbed, her child reaching out to her mother. But a black cloud has already been cast upon the child, as evident by an unmistakable dark patch on her neck (similar to the father), and the deformed leg—a sign of syphilis.  Quacks don’t heal; they conceal. And that will out.

Fig. 2: Marriage a la Mode, Platte III, The Inspection, Illustration from ‘Hogarth Restored: The Whole Works of the celebrated William Hogarth“.

Little had shifted in public opinion concerning beauty quacks in the age of Victoria, the age that gave rise to modern cosmetic surgery. But much had shifted in the age of modern scientific medicine since John Taylor. Two factors: anesthesia and antisepsis moved what were relatively rare and risky procedures into more acceptable and less fraught arenas. Even with the continued stigma of disguise and disease. By the beginning of the age of chemistry, bench science developed one of the first general anesthetics [6]. Joseph Priestly, who first describes oxygen and its functions, describes nitrous oxide in 1772. And a very young Humphrey Davy observed in 1795 ‘as nitrous oxide in its extensive operation appears capable of destroying physical pain, it may probably be used with advantage during surgical operations in which no great effusion of blood takes place [7]. While anesthesia became slowly accepted and central to the practice of surgery after the demonstration of nitrous oxide as an anesthetic, by the dentist Horace Wells in 1844, and then, of ether by yet another dentist, William Thomas Green Morton in 1846.  But it was the acceptance of such amelioration by the medical establishment that was necessary for anesthesia to become an acceptable intervention [8]. Chloroform quickly followed when employed by the surgeon, Sir James Young Simpson in 1847, following its development by the medical student Robert Mortimer Glover in 1840. They were ‘shouting in the marketplace’ and are thus Wells, Morton, and Simpson were given the priority of discovery of anesthesia even though all of the substances were well known beforehand [9]. The further development by the beginning of the age of scientific medicine of local anesthesia, in the form of cocaine for surgery of the eye by Karl Koller in 1884, as well as what will be called novocaine, synthesized by Alfred Einhorn, a professor of chemistry at the University in Munich, initially as a local dental anesthesia, which quickly sought to replace tincture of cocaine. Both were products of what was already in the closing decades of the 19^th century a huge web of pharmaceutical companies shaping medical practice: Koller used materials developed by Merck in Darmstadt and Einhorn patented the materials he developed at Meister, Lucius, and Brüning at Höchst [10]. Local anesthesia meant that the greater risk of dying under general anesthesia could be avoided.

Antisepsis paralleled the development of anesthesia. In 1867 Joseph Lister provided a model for antisepsis which became generally accepted by the end of the century. In an age a mere scratch could lead to death.  The poet Rainer Maria Rilke dies in 1927, well into the age of antisepsis, and it was claimed that: ‘Rilke gathered some roses from his garden.  While doing so, he pricked his hand on a thorn. This small wound failed to heal, grew rapidly worse, soon his entire arm was swollen, and his other arm became affected as well [11]. The avoidance of infection meant that patients’ anxiety about cutting the skin in surgery was lessened, indeed seemed less risky than even a rose’s thorn. The acceptance of antisepsis was relatively slow but was strongly encouraged by cosmetic surgeons. On November 26, 1877, Robert F. Weir, one of the major figures in the creation of American cosmetic surgery, said in a talk before the New York Medical Association, that the British and German acceptance of this procedure had outpaced that of the United States. He urged that the smallest detail of the cleansing of patient, surgeon, instruments, and surgical theater be carried out so that the patient not placed at needless risk. Once this was done, the risks attendant on cosmetic surgery decreased sharply because of the reduction in the high incidence of infection [12]. No pain, no pus, much gain.

Fig. 3: Joseph Lister the „Father of antiseptic surgery“.

By the nineteenth century and the rise of cosmetic surgery there is also a shift in the goal of medical intervention: it was to make the patient happy as well as healthy. The utilitarian notion of happiness stressed the autonomy of the individual, as found in John Stuart Mill’s (1806-1873) Utilitarianism (1863). In what becomes a commonplace, Mill wrote ‘actions are right in proportion as they tend to promote happiness; wrong as they tend to produce the reverse of happiness [13]. And Mill’s focuses on the happiness of the individual as his highest good rather than the tradition notion of the happiness of the collective. What is good for me makes me happy, the popular view might go, rather than what is good for the world in which I live. This is a sort of post-Kantian ideal categorical imperative of happiness. A right action is defined by individual desire limited by its impact on others. Here is the ethical core of modern cosmetic surgery.

Scientific medicine had reduced the speaking subject to the clinical specimen; the old man with a pain in the chest became the ‘heart attack in Bed A [14]. In the age of the Enlightenment the great American physician – patriot (he signed the Declaration of Independence) Benjamin Rush taught:

Physicians by reviewing the history of complaints from their patients will often have them exaggerated but by frequent visits you cannot be deceived. Endeavor to get the history of the disease from the patient himself and do not interrupt him till he has finished as he will always give the best symptoms tho’ he may give the worst causes. Begin to interrogate your patient. By how long he has been sick? When attacked and in what manner? What are the probable causes, former habits and dress; likewise the diet, etc., for a week before especially in acute diseases….  In chronic diseases enquire their complaints far back and the habits of life…. Pay attention to the phraseology of your patients, for the same ideas are frequently conveyed in different words. A pain in the precordia is called by an Englishman a pain in his stomach, by a Scotchman in his breasts, an Irishman in his heart and by a Southern man mighty poorly. Enquire of your patients the diseases of their ancestors, the age to which they lived and the remedies which relieved them. It is of consequence because there is a hereditary idiosyncrasies in some families. Patients often conceal the cause of their disease — therefore interrogate them particularly when you suspect intemperance as the cause of disease [15].

Fig. 4: Portrait of Dr. Benjamin Rush by Charles Willson Peale, dated 1783-1786. Winterthur Museum

In the age of scientific medicine, William Osler apocryphally must admonish his medical students to ‘listen to your patient, he is telling you the diagnosis [16]. And this was strongly supported by the patients themselves.  In the closing years of the 19^th century the director of a renowned London teaching hospital overheard a man saying to another patient: ‘‘As to them blooming doctors, we teach ‘em a lot, I know. Lor’! how they do jaw about our insides to them blokes as sits and looks on [17]. The director, in the spirit of the new medical science, disavowed the patient’s autonomy: ‘The advance of a spirit of surly independence is to be noticed among hospital patients. Time was when as a class they were not ashamed to be grateful [18]. Osler was quite right. Listening had become reduced to reaffirmation, the classic history to the reification of the physician’s diagnosis. Indeed, contemporary medical practice in the 21^st century has had to stress over and over again the need to listen, to respect and act on the patient’s sense of self, as one report in 2011:

. . I’ve always been a firm believer that the patient often knows better than we do what the appropriate treatment is. I’ve had many patients tell me ‘enough already,’ and I’ve always had the attitude: What do you mean enough already? Often when it gets to the point of ‘enough already,’ we’re not listening to the patient. They often know much better than we do [19].

This tension frames the debate about patient autonomy during the age of scientific medicine and the rise of cosmetic surgery.

Thus, the first generation of cosmetic surgeons to work in both the age of modern medicine, anesthesia, and antisepsis, as well as the professional limits set by scientific medicine: ‘Do no harm!’ Raymond Passot, a pupil of the cosmetic surgeon Hippolyte Morestin in Paris, included in 1919 and through the 1920s mention of the positive effect that these operations have on a patient’s morale, and the important social benefits that these operations provide [20]. In the United States it was Adalbert G. Bettman who in 1929 considered both the psychological and the social impact of plastic surgery. In his essay on the ‘psychology of appearances,’ he argues that patients suffering from mental discomfort due to their deformities are afflicted with genuine illnesses. The importance of plastic surgery to the individual patient is emphasized by his oft-quoted remark that ‘a large and noticeable defect offers no inconvenience or psychological reaction, no hindrance to our success or well-being when on someone else’s face [21]. Vilray P. Blair, one of the founders of the American Board of Plastic Surgery, in 1936 provided a common-sense interpretation of the interrelated psychosocial effects of plastic surgery. He presents a balanced view of the factors involved in head and neck surgery, recognizing both the effect of deformity on the patient’s psyche and on her/his social circumstances. He views deformity as a handicap in ‘life’s struggle,’ and acknowledges particularly the economic hardship that deformity causes [22].

The Berlin surgeon Jacques Joseph’s claim to fame was his solving of the surgical problem of the visible scar. His procedure to remove the bone and cartilage from within the patient’s nose is still used today as are the surgical tools he used to carry out the procedure. In his summary paper on the reduction of the size of the nose published in 1904, Joseph commented on the psychology of his male patients: ‘The patients were embarrassed and self-conscious in their dealings with their fellow men, often shy and unsociable, and had the urgent desire to become free and unconstrained. Several complained of sensitive drawbacks in the exercise of their profession. As executives they could hardly enforce their authority; in their business connections (as salesmen, for example), they often suffered material losses. […] The operative nasal reduction – this is my firm conviction – will also in the future restore the joy of living to many a wretched creature and, if his deformity has been hindering him in his career, it will allow him the full exercise of his aptitudes [23]. According to Joseph the patient ‘is happy to move around unnoticed.’ But this leads also to a major innovation to make his patients ‘happy,’ the move from a general anesthesia to rhinoplasty under local anesthesia, with a reduction of both risk and psychological trauma [24]. In his magnum opus, his handbook of cosmetic surgery, Rhinoplasty and Facial Plastic Surgery with a Supplement on Mammoplasty and Other Operations in the Field of Plastic Surgery of the Body of 1931 he observed that he been using local anesthetic,75 ‘a 1% solution of cocaine with adrenalin in physiologic saline solution’ for many years,’ before moving to novocaine in the late 1920s.’ He stressed that ‘local anesthesia is preferred whenever possible if only because it enhances asepsis.’ And he found that ‘in the vast majority of facial plastic surgery cases, local anesthesia maybe used; at least, I have performed almost all facial plastic surgeries, even the most extensive ones … using local anesthesia [25]. His students, and he had many local and foreign students observing in his clinic, were ordered them to be silent during surgery, as he was keeping his patients awake and he did not want their comments to disquiet them. For only ‘major’ surgery was now becoming defined by general anesthesia, local anesthesia had become the tool of the specialist surgeons. Thus Adalbert Bettman, at the University of Oregon’s School of Medicine and one of the physicians who claim to heal the psyche as well as operate on the body, undertook one of the earliest face lifts ‘…using a 2% solution of novocaine and adrenalin for local anesthesia [26]. And these interventions were no longer perceived by the patients as life-threatening.  For the patient’s goal was their own happiness.

The ‘psychoanalytic turn’ in the explanation of the psychosocial effects of plastic surgery appears by the 1930s. Howard L. Updegraff and Karl Menninger’s classic 1934 article makes a distinction between grave and minor deformities, something that had professionally come to be a boundary between the new fields undertaking ‘Reconstructive Surgery’ after WWI and the field of aesthetic or cosmetic surgery, which had proceeded it provided many of these self-same surgeons with the methods that they use to reconstruct war-damaged visages.[i] If your defect is seen by the medical establishment to distort then surgery is appropriate; if not, well then it is vanity surgery or psychosurgery. They explain in psychoanalytic terms the patients’ motivations for seeking surgical repair of ‘trivial’ defects. They conclude that most patients presenting for cosmetic (minor) plastic surgery are impelled by narcissism, and that these patients assuage the guilt engendered by the gratification of this narcissism through the physical pain that accompanies their surgery. Through their analysis, they directed the foundation for further research that explores the psychiatric implications of plastic surgery. Here we should allow a clarifying word: ‘Attitudes of a given society may determine not only what constitutes deformity, but to what extent an individual with facial deformity is to be accepted or not accepted as a member of the group. This impairment is not physical but is determined by the prejudices and disapproval of the group for those with abnormal faces [28]. Even with Sigmund Freud’s admonition that ‘happiness’ was not the goal of analysis; it turns out that it was the goal of cosmetic surgery. Yet happiness is a ‘peculiarly modern, Western idea,’ as Richard Sennett has observed [29]. Actually happiness is multiple, conflicting ideas — often changing from context to context with each change presaging a cascade of different meanings and interpretations.  For Joseph’s patients it was a particularly fraught moment. Visibility is the the hallmark of the new ‘science of race’ — races ‘look’ different. Only vanishing into the visual norm and passing in terms of his appearance enabled anyone who would be categorized as ‘racially’ different to become part of the general society, to be happy.

One of the most knowledgeable cosmetic surgeons before W.W.I, Frederick Strange Kolle distinguished between reconstructive surgery of the nose applied to ‘deformities when caused by traumatism, the excision of neoplasms or destructive disease’ and ‘such corrections [which] are made purely with the object of improving the nasal form when the deformity is either hereditary or the result of remote accident.’ (Missing external ears [microtia] versus Dumbo Ears, FA Cup Ears, Jug Ears, Wing-Nut Ears, or Taxi-Door Ears, that is ears that stick out too much and thus were and are mocked.) He continued however: ‘For some unaccountable reason [cosmetic surgery] has not met with the general favor the profession should grant it, yet the results obtained by such specialists as have undertaken this artistic branch of surgery have been all that could be desired, and have consequently added much to the comfort and happiness of the patient [30]. Listening to the patient without evident ‘need’ (as defined by the surgeon) can indeed improve lives as much as the reconstruction of the face, which results from an ‘objective’ assessment of the surgeon of the patient’s needs. The Portland, Oregon ‘beauty’ surgeon Adalbert G. Bettman (1883-?) who wrote in 1929 that cosmetic surgery ‘has been perfected to such a degree that it is now available for the improvement of the patient’s mental well-being, their pursuit of happiness [31]. Happiness is clearly here a psychological benefit of a surgery to reduce misery, not surgery on the body but surgery on the psyche, as Joseph had claimed in the 1890s.

Many of the same procedures developed by 19^th-century surgeons such as Joseph come to be labeled as ‘reconstructive’ during WWI.  Joseph treats many of the war wounded through procedures labeled as ‘quackery’ just a decade before the war and is recognized by the state for doing so.  And this is equally true in Great Britain and France. Yet there remains even in the 21^st century a sense of the fraud about such procedures, even after the dean of WWI reconstructive surgeons, the New Zealander Harold Delf Gillies is knighted and given an OBE, mind you, only in June 1930 for his work during WWI. The self-conscious rise during the closing decades of the nineteenth- and the opening decade of the twentieth century of surgeons who saw themselves as ‘beauty’ surgeons was challenged by a claim of the post-war reconstructive surgeons who saw this as incidental to their practice. Gillies advocated seeing ‘cosmetic surgery’ as a natural subordinate extension of ‘reconstructive surgery.’  In 1934 he called the field: ‘cosmetic, reconstructive surgery.’ He also condemned the ‘poorly qualified and very well advertised surgeons [who] have adopted the term, plastic surgery, without any true training in surgery and without any other surgical ability than to remove a few folds of skin or a small hump of the nose.

…  It is so easy to agree to do some cosmetic operations which may in fact not be justified, and it is so troublesome, sometimes, to decide whether in a particular patient the proposed operation will give that pleasure and satisfaction which it would in another [32]. Gillies, according to the most recent biographical study was passionate about both reconstructive surgery and its lesser cousin, cosmetic surgery, which allowed him a greater client base [33].

Unlike some other surgeons confronted with badly wounded soldiers, who were committed only to making sure that the patient survived, Gillies attempted to restore the man’s original appearance as well as the functionality of his eyes, nose, and mouth. Gillies’ and other surgeons’ goal was ‘beauty and symmetry…the fundamental ideals of reconstructive surgery.’ It was ‘essentially…sculpturing with live tissues for material [34]. This new form of surgery was a synthesis of regaining both the functional and the cosmetic operations of the face.  Not either/or but both simultaneously.

With little irony Gilles, certainly the most famous British reconstructive surgeon in WWI, was followed in his role by his cousin Archibald McIndoe, whose exploits in WWII with Battle of Britain pilots, mostly burn cases, made him into one of the heroes of the day. We can note that the most famous reconstructive surgeon on the side of the Central Powers, was Jacques Joseph, who unlike Gilles, was immediately rewarded for his expertise. Having been dismissed from academic medicine, and therefore with any ‘Habilitation,’ he was appointed head of the newly founded Department of Facial Plastic Surgery at the Ear, Nose and Throat Clinic at the major public hospital in Berlin, the Charité, by the Prussian Ministry of Education and Cultural Affairs in 1916. In 1919, he was promoted to Professor and was awarded the Iron Cross. In 1922 he opened a private practice for cosmetic surgery in Berlin and was feted as a celebrity in the daily papers.

When Gillies urged his cousin to follow in his footsteps in the interwar period, Adonia Aitkin, McIndoe’s wife, excoriated Gilles as ‘the idea that he was going to sacrifice this skill to become what she called ‘a Bond Street quack,’ a male beauty specialist filled her with fury and dismay.… ‘I’m not going to have seven years of my life thrown away in order to see him become a face-lifter’ [35]. Cosmetic surgeons remain socially and medically marginal.  As one of the early American surgeons, Charles Conrad Miller, who began his practice in Chicago in 1903, recorded in 1907, ‘The regular profession has disregarded the educational tendencies of … thousands of columns of [newspaper] space, and when a woman or man consults the family physician regarding some defect of facial outline or fault of skin, the physician merely laughs and ridicules.’ But the modern cosmetic surgeon ‘… who operates or treats these cases has the future happiness and peace of mind of the patient at stake [36]. And that changes little after WWI, when surgeons such as Miller begin to flourish on the margins of the American medical profession. Vilray Blair, who had a chair of surgery at the Washington University School of Medicine in St, Louis, headed the United States Army maxillofacial unit during WWI and thus was the American parallel to Gilles, ‘as a sort of gamble, . . . persuaded the Surgeon General later to change his title to Chief of Plastic Surgery,’ in this way once again buttressing the field with the reputation his work had earned during the war [37]. After WWI, cosmetic surgery becomes more accepted within scientific medicine, but always with a stigma, as much on the patient as the surgeon.

Are they quacks in the eyes of the establishment (and recently knighted) reconstructive surgeon?  The ‘quackery’ was, however, not very much different in its approach and success from the procedures developed and used by surgeons within the medical establishment undertaking similar procedures.  The label ‘quack’ was used to limit the investiture of those permitted to undertake ‘serious’ interventions. And employing the ‘cutting-edge’ (pun intended) medical procedures including local anesthesia and field antisepsis. But there seemed to be an out for such ‘quacks.’

The conflicts that formed modern cosmetic surgery drew other lay practitioners into the fold, where they sensed the slippage of the claims of surgical intervention. The Anglo-American artist-poet Minna Loy wrote ‘Auto-Facial-Construction’ during 1918-1919 in Italy, though it was first published as a pamphlet in Paris and distributed under the aegis of the Societaire du Salon d’Automne, the prestigious bohemian salon that had first begun exhibiting her artwork in 1903. Her intervention was non-surgical but made the same promises as the now rejected paraffin injections used to smooth out the skin and eliminate wrinkles, were falling out of favor because of paraffin’s toxicity. Exemplary, at least in the press, was the fate of the ‘most beautiful woman in Christendom,’ Gladys Marie Spencer-Churchill, Duchess of Marlborough who tried to even a small nasal tip asymmetry with paraffin and had some injected into her jaw. The procedure caused major deformities to the point that she became a recluse. Loy’s intervention, exercises for (supposedly) achieving the ideal mimetic relation between one’s face and one’s personality, paralleled the surgical work of the first generation of cosmetic surgeons, such as Eugen Holländer, whose development of the surgical face-lift was first developed around the turn of the century, putatively in response to the demand for a safer procedure to replace paraffin injections [38]. Loy piggybacks on this as her title hints at the medical term autoplasty (deriving from the Greek ‘self-formed’), a designation for plastic and reconstructive procedures that was in use in the early twentieth century. Loy specifies, ‘My system … does not include any form of cutaneous hygiene’ and promises that ‘Through Auto-Facial-Construction the attachments of the muscles to the bones are revitalized.’ And capitalizing on the Futurist obsession with eternal youth and the dream of a body that expresses a rapidly changing modernity, Loy writes: ‘Day by day the new interests and activities of modem life are prolonging the youth of our souls, and day by day we are becoming more aware of the necessity for our faces to express that youthfulness, for the sake of psychic logic [39]. An answer to the doc’ or just another quack building on the recent popularity of cosmetic procedures and their failures?

But cosmetic surgery remained quack surgery in spite of all, as Archibald McIndoe’s wife had proclaimed.  In 1934 Jacques W. Maliniak attacked the ‘brazen quackery that has attended the development of modern plastic surgery…[40]. The mandibular surgeon Henry Junius Schireson was denounced as ‘king of the plastic surgery quacks’ in the A. M. A.’s popular medical journal.  Schireson’s claim to fame was that he had in August 1923 altered the comedienne Fanny Brice’s nose to make her look, well, less Jewish, on the Broadway stage. She wanted a ‘normal’ nose.

This led to Dorothy Parker’s not too subtle observation about people cutting off their noses to spite their race [41]. But it was the gullibility of the patient that defined his ability to be a quack.  First, as we have already noted, the new immigrants into the cities, the Eastern European Jews like Fanny Brice, and ‘Later, emboldened by the ease of his success, he added dupes from among the farmers and merchants of New England, the movie stars of New York and Hollywood, Chicago’s captains of industry and finance, Philadelphia’s society matrons. …he [practiced] his grisly arts on the dumb, the suffering, the credulous [42]. His patients sought not merely surgical intervention but a competent ‘doctor who is fully aware of the emotional components of the problem will not pass this interest off lightly, for he will discern behind it the full impact of life’s plan, hope and aspirations, all of which seem to be in imminent danger of collapse [43].

Happiness was the promise but it was a chimera. ‘Like the putrid fungus the quack thrives in darkness — the darkness of men’s minds.… In the failure of people to acquire knowledge, agencies of government must protect the fools against their folly, the ignorant against their lack of knowledge, the stupid against their inability to reason. How long will these agencies continue to tolerate Henry Junius Schireson? [44] Yet was it avarice on the part of the physician or ignorance on the part of the patient that was the core problem? ‘We have cults and quacks, too.  I think cultism and quackery are deplorable, but if I were to be forced to choose between rigid suppression of all unorthodox practitioners or a program of enlightenment and education looking toward their elimination by the people’s choice, I would choose the latter,’ wrote W. W. Bauer in the same issue of the American Medical association’s popular journal [45]. But this also reflects an on-going process of refining the boundary between quackery and medicine, especially in the light of the explosion in the availability of daily newspapers.  Charles Miller, whose textbook of 1907, The Correction of Featural Imperfections, was one of the first to detail the breadth of cosmetic surgery, has been labeled ‘something of a quack and at the same time something of a surgical visionary,’ a not uncommon mix as we have seen [46]. He refers to the sort of competition a licensed surgeon faced from non-medical purveyors, and comments on the results of such treatment: ‘The criminal carelessness of advertisers is unbelievable to those who have not seen the results of their utter disregard for patients.’

Many patients have consulted me who have been mutilated by advertisers and I have yet to find out who, before submitting to the advertiser for treatment, had not consulted a regular physician in good standing.  These ethical physicians, while ridiculing the desires of the patients, could not conceal the fact that they were totally ignorant of this special subject. The regular profession has disregarded the educational tendencies of . . . thousands of columns of [advertising] space and when a woman or man consults the family physician regarding some defect of facial outline or a fault of skin, the physician merely laughs and ridicules [47].

Who in the end is the ‘quack’ and who the ‘doc’?