Critical Dialogues in the Medical Humanities [1 ed.] 1527534634, 9781527534636

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Critical Dialogues in the Medical Humanities

Critical Dialogues in the Medical Humanities Edited by

Emma Domínguez-Rué

Critical Dialogues in the Medical Humanities Edited by Emma Domínguez-Rué This book first published 2019 Cambridge Scholars Publishing Lady Stephenson Library, Newcastle upon Tyne, NE6 2PA, UK British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Copyright © 2019 by Emma Domínguez-Rué and contributors All rights for this book reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the copyright owner. ISBN (10): 1-5275-3463-4 ISBN (13): 978-1-5275-3463-6



TABLE OF CONTENTS

Acknowledgements ................................................................................... vii Introduction by Emma Domínguez-Rué ...................................................... 1 Part 1: Evidence-based and Patient-centred Care Chapter One ................................................................................................. 8 Action Competence as a Key Notion for Patient-Centred Care Arto Mutanen Chapter Two .............................................................................................. 22 Utilization of Gynaecological Care and the Role of the Gynaecologist in Cytological Prevention in the Light of a Nationwide Survey in Poland Wáodzimierz Piątkowski and Anna Dudkowski-Sadowska Chapter Three ............................................................................................ 37 Enemies of the People: Just Who is Entitled to use Evidence-based Critiques of Vaccination? Stephen Wallace Part 2: Defining Medical Space Chapter Four .............................................................................................. 56 Operating Room or Operating Theatre? Defining “Surgical Theatrics” on the Surgeon's Stage Cindy Avila Chapter Five .............................................................................................. 72 Spa Architecture in Szczawno-Zdrój Maria Skomorowska Chapter Six ................................................................................................ 83 The Garden as a Twenty-first Century Panacea? Trends in Shaping Gardens at Hospitals. A Case Study of Complexes in England and Poland Daria Sáonina



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Table of Contents

Part 3: Exploring Medical History Chapter Seven.......................................................................................... 108 The Onion (Allium Cepa L.) in Late Ancient and Early Byzantine Medical Literature (I–VII Centuries AD) Krzysztof Jagusiak and Maciej Kokoszko Chapter Eight ........................................................................................... 126 The Changing Face of Glaucoma in History Tereza Kopecka Chapter Nine............................................................................................ 141 Anthropology in Social Sciences and Popular Prose between Futuristic Fear and Advanced Algorithms: Human Obsolescence or Opportunity after Alliance with Artificial Intelligence, Nanotechnology, Social Robotics, and the Automation Economy? Konrad Gunesch Part 4: Literary Portraits of Medicine Chapter Ten ............................................................................................. 164 Hunger Divine: Religious Elements and Cultural Assumptions about the Female Body in American Women's Narratives of Anorexia Emma Domínguez-Rué Chapter Eleven ........................................................................................ 186 Wilkie Collins’ Heart and Science and the Axiological Indeterminacy of Medical Discourse Emanuela Ettorre Chapter Twelve ....................................................................................... 198 “[T]he Darker Side” of Medicine: The Victorian Novel and the “Scientization” of the Medical Professional Adrian Tait Chapter Thirteen ...................................................................................... 215 The Mute Body: Illness and Family Crisis in Late Imperial Chinese Fictional Medical Narratives Ying Wang Contributors ............................................................................................. 231





ACKNOWLEDGEMENTS

This volume would not have been possible without the engaging interdisciplinary dialogue initiated at the conferences organised by the London Centre for Interdisciplinary Research. The editor would like to thank the LCIR for having trusted her with the edition of this volume, and acknowledge the ongoing support and tremendous help of its Director Olena Lytovka. To her goes my most sincere gratitude.





INTRODUCTION EMMA DOMÍNGUEZ-RUÉ

All of us – either as medical practitioners, healthcare providers, or healthcare users – have some insight into good doctoring; namely, pick the doctor with the longest waiting list at your local healthcare centre. From that awareness, one can infer that we all realise, maybe to various degrees, about the importance of Medical Humanities. As Jack Coulehan aptly defines them, “medical humanities relates to, but is not identical with, the art of medicine, for which nowadays we often use the word ‘doctoring.’ Doctoring requires communication skills, empathy, self-awareness, judgment, professionalism, and mastering the social and cultural context of personhood, illness, and health care” (2008). In that light, and as Martyn Evans and David Greaves discuss (1999, 1216), the Medical Humanities should not just attempt to add the humanities to existing medical knowledge, but actually try to integrate them into medical practice. In other words, and as Femi Oyebode asserts, to “refocus medicine” in such a way “that it comes to incorporate within its ambit what it means to be fully human” (2010, 242). As Rita Charon sustains in her foundational book Narrative Medicine (1998), medical practitioners can highly benefit from incorporating sources and methods from the humanities to better accompany their patients in their illness, thus contributing to more humane – and ultimately more effective – medical care. As this volume hopes to illustrate and as Charon et al. have discussed (Charon et al. 1995; 122, 599–606), literary accounts of illness can enlighten a doctor’s perspective on a clinical case, while adopting the role of listener to the narrative of a patient’s disease can help a doctor understand patients and their distress more deeply. As Oyebode similarly writes, “fiction can inform physicians of the power and implications of what they do; and understanding narrative structure can help physicians grasp patient’s [sic] stories more fully among other things” (2010, 7). However, Jakob Ousager and Helle Johannessen have pointed out that there is scarce evidence of the positive impact of integrating the Medical Humanities into the curricula of Medical School undergraduates, which might in turn “pose a threat to the continued development of

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Introduction

humanities-related activities in undergraduate medical education in the context of current demands for evidence to demonstrate educational effectiveness” (2010, 988). Anna Taylor, Susan Lehmann and Margaret Chisolm have similarly remarked that, even if the significant benefit of integrating the humanities in medical practice has been widely accepted, “very little has been done to evaluate its use in practice”, while pointing out that “future studies should focus on gaining qualitative and quantitative data regarding impact of curricular interventions on learners and/or patients” (2018, 6). In this respect, Johanna Shapiro et al. (2009, 197) have proposed a “cross-disciplinary, collaborative recontextualization of medicine” in order to take the scholarly traditions in the humanities to the core of medical education, so that “these disciplines be seen not only as ‘nice’ but also as essential.” As Shapiro et al. contend, “we will be able to use the humanities’ intricate and sympathetic knowledge about the human condition (sophia) as well as its [sic] ability to examine particularistic, experiential knowledge (phronesis) to help ensure a morally sensitive, narratively sound, and deeply professional clinical practice (praxis)” (2009, 197). It is with this purpose in mind that Critical Dialogues in Medical Humanities modestly attempts at illustrating ongoing discussions in and about the Medical Humanities with studies on different approaches to the relationship between medical science and/or practice and the humanities – including reflections based on fiction, art, history, socio-economic and political concerns, architecture and natural landscapes. The first section in the volume, “Evidence-based and Patient-centred Healthcare”, includes three chapters that explore the ways in which healthcare and medical practice can be positively influenced by removing the focus from the technical knowledge of the medical practitioner. In “Action Competence as a Key Notion for Patient-centred Care”, Arto Mutanen discusses how medical practice is often seen as a combination of technical competence (based on medical knowledge) and ethical competence, and examines the nuances of trying to define and evaluate the latter. The author proposes the notion of action competence as a valuable tool to balance the technical and ethical competence of the medical practitioner and establish a relationship between the doctor and patient that enhances caring and thus contributes to developing clinical practices in which human dignity is a crucial value. In “Utilization of Gynaecological Care and the Role of the Gynaecologist in Cytological Prevention in the Light of a Nationwide Survey in Poland”, Wáodzimierz Piątkowski and Anna Dudkowski-Sadowska present the results of a socio-medical study that analysed Polish women’s experiences in relation to their use of gynaecological care, while underscoring the

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significance of developing the socio-psychological competences of the medical practitioner as substantial to improving gynaecological practice. Finally, Stephen Wallace problematises the controversial issue of vaccine policies in an article that bears the provocative title “Enemies of the People: Just Who is Entitled to use Evidence-based Critiques of Vaccination?”. The plight of Thomas Stockmann, the protagonist of Henrik Ibsen’s Enemy of the People, is used as a metaphor to illustrate the reaction to critical views against vaccination and poses the question of who is actually endorsed to sanction or censure certain health policies. The second section, entitled “Defining Medical Space”, offers three innovative perspectives on spaces for healing, which include traditional medical spaces and beyond. Cindy Avila uses art to analyse operating rooms and, by extension, surgery in “Operating Room or Operating Theatre? Defining 'Surgical Theatrics' on the Surgeon's Stag”. The author makes a close description of two paintings from the end of the 19th and 20th centuries respectively, which serve as an apt illustration to her examination of certain aspects of surgery that reach beyond medical matters. In “Spa Architecture in Szczawno-Zdrój”, Maria Skomorowska carefully and thoroughly describes the development of the Polish spa Szczawno-Zdrój in Silesia (Poland) since its inception in the nineteenth century to the present, detailing its progress and change in order to adapt to the needs of its patients. Similarly, Daria Sáonina makes a comparative study of hospital gardens in Poland and the United Kingdom in “The Garden as a Twenty-first Century Panacea? Trends in Shaping Gardens at Hospitals. A Case Study of Complexes from England and Poland”, where the structure and elements of hospital gardens serve the author to comment on the healing potential of this often neglected space in medical institutions. “Exploring Medical History”, the third section in the volume, includes three interesting chapters that trace attitudes and beliefs in relation to illnesses and their treatment – and thereby the evolution of medical practices – through historical periods, including intimations of the future. Krzysztof Jagusiak and Maciej Kokoszko offer a detailed account of the medical properties of the onion according to Byzantine writings in “The Onion (Allium Cepa L.) in Late Ancient and Early Byzantine Medical Literature (I–VII Centuries AD)”, where the authors use the onion to exemplify the various uses and treatments based on the natural properties of plants in ancient Byzantium. In “The Changing Face of Glaucoma in History”, Tereza Kopecka describes the development of medical treatment for glaucoma while at the same time illustrating the human side of the disease in a moving and sensitive way through the written accounts of a

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Introduction

family affected by glaucoma over various generations. Finally, the section closes with interesting speculations about the future of medical care. In “Anthropology in Social Sciences and Popular Prose between Futuristic Fear and Advanced Algorithms: Human Obsolescence or Opportunity after Alliance with Artificial Intelligence, Nanotechnology, Social Robotics, and the Automation Economy?”, Konrad Gunesch analyses recent scholarly writings on the impact of new technologies. Using examples from contemporary fiction, the author discusses whether developments such as automated healthcare providers signal human unreliability in front of the infallibility of machines, or rather the need to reconcile technological advance with a more humanistic view of science. In the final section of the volume, “Literary Portraits of Medicine”, four chapters interrogate cultural attitudes to illness, doctoring and patients through the lens of fiction. In the first chapter, “Hunger Divine: Religious Elements and Cultural Assumptions about the Female Body in American Women's Narratives of Anorexia”, Emma Domínguez-Rué uses contemporary examples of American confessional literature to examine notions of religious ascetics – transgression, punishment, reward, denial and control – and the extent to which fiction can reveal the negative impact of certain cultural values attached to women’s behaviour as well as their role in triggering eating disorders. Emanuela Ettorre interrogates 19th century medical science through a Victorian sensation novel in “Wilkie Collins’ Heart and Science and the Axiological Indeterminacy of Medical Discourse”, where she illustrates the author’s use of sensationalism to disclose how the medical profession displayed the moral ambivalence of the period. In “‘[T]he Darker Side’ of Medicine: The Victorian Novel and the ‘Scientization” of the Medical Professional”, Adrian Tait also uses Collins’ narrative Heart and Science as well as other Victorian works to consider modern medical knowledge and its impact – not only on the doctor/patient relationship but in the gradual dehumanization of the doctor himself. In the last chapter in the volume, “The Mute Body: Illness and Family Crisis in Late Imperial Chinese Fictional Medical Narratives”, Ying Wang uses examples from Chinese medical narratives to examine sickness as a metaphor, which not only causes suffering and alters the sick person’s identity, but also potentially destroys family dynamics and ethics, and even brings about political disruption. As Richard Meakin and Deborah Kirklin have noticed, if knowledge of Medical Humanities has proved to be beneficial for a better medical practice and is to be incorporated in curricula, not only suitable assessment methods must be implemented but the degree of efficiency of practitioners

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must also be properly verified, while more interdisciplinary work between medical and non-medical professionals is needed: educators will need to develop appropriate evaluative methods, not only to assess student achievement but also to demonstrate the effectiveness of this form of teaching in meeting the educational objectives laid down ...The first step towards achieving these objectives needs to be the sharing of ideas and experiences throughout the field and across disciplines. (2000, 49)

In our modest attempt to generate interdisciplinary work in this field, we hope the chapters contained in this volume will make a further contribution to an ongoing dialogue between medicine and the humanities that continues to enrich both disciplines. As Kirklin and Meakin quote from Chekhov, “the sensitivity of the artist may equal the knowledge of the scientist. Both have the same object, nature, and perhaps in time it will be possible for them to link together in a great and marvellous force which is at present hard to imagine” (2000, 49).

References Charon, Rita. 1998. Narrative Medicine. Honoring the Stories of Illness. Oxford, OUP. Charon, Rita, Trautmann Banks, J., Connelly, J. E. et al. 1995. “Literature and Medicine. Contributions to Clinical Practice.” Annals of Internal Medicine 122: 599-606. Coulehan, Jack. 2008. “What is Medical Humanities and Why?” Lit Med Magazine https://medhum.med.nyu.edu/magazine/?p=100. Evans, Martyn and Greaves, David. 1999. “Exploring the Medical Humanities.” British Medical Journal 319: 1216. Meakin, Richard and Kirklin, Deborah. 2000. “Humanities Special Studies Modules: Making Better Doctors or Just Happier Ones?” Journal of Medical Ethics 26: 49-50. O'Neill, Desmond, Jenkins, Elinor, Mawhinney, Rebecca, Cosgrave, Ellen, O'Mahony, Sarah, Guest, Clare and Moss, Hilary. 2016. “Rethinking the Medical in the Medical Humanities.” Medical Humanities 42 https://doi.org/10.1136/medhum-2015-010831. Ousager, Jakob and Johannessen, Helle. 2010. “Humanities in Undergraduate Medical Education: A Literature Review.” Academic Medicine 85/6: 988-998. Oyebode, Femi. 2010. “The Medical Humanities: Literature and Medicine.” Clinical Medicine 10/ 3: 242-244.

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Shapiro, Johanna, Coulehan, Jack, Wear, Delese, and Montello, Martha. 2009. “Medical Humanities and their Discontents: Definitions, Critiques, and Implications.” Academic Medicine 84/2: 192-198. Taylor, Anna, Lehmann, Susan, and Chisolm, Margaret. 2018. “Integrating Humanities Curricula in Medical Education: a Literature Review.” MedEdPublish https://doi.org/10.15694/mep.2017.000090.2.



PART 1 EVIDENCE-BASED AND PATIENT-CENTRED CARE

CHAPTER ONE ACTION COMPETENCE AS A KEY NOTION FOR PATIENT-CENTRED CARE ARTO MUTANEN

Introduction The notion of action competence is well-known in health and medical sciences as an essentially reactive notion: if the health condition of a patient collapses, then the problem is how to restore the action competence of the patient. The intention of any intervention or treatment is to restore the patient’s action competence at least partially. This kind of characterization brings to mind the essentially reactive notion of resilience. The reactive characterization is not a bad one as such, but the reactive characterizations of a human’s action competence see a human being as an object: an object of (restoring) operations or of healing activities. Action competence can be naturally understood as an ontologico-methodical notion: a human being is not merely a being with action competence, but he or she acts under his or her own power. This is the actual potentiality of a human being, which becomes the self-expression of a human being. Thus, a human being does not have an action competence which can be “objectively” characterised as more or less complete. This entails that medical care does not just restore or perform operations on a patient, but is a form of caring in which a medical doctor is a knowledge-based person with a high degree of responsibility. This emphasises human dignity as a fundamental value of medical care.

Medical Philosophy In the philosophy of medicine, notions of health and disease have played a central role. Even if they are of extreme importance, there is no generally agreed characterization of notions. The lack of a generally accepted characterization does not refer to the intellectual laziness of

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philosophers of medicine but the extreme complexity of the topic. Notions of health and disease are connected to the very foundation of humanity. Moreover, these notions are interlinked. That is, a healthy person does not have a disease while a sick person does have a disease and hence is not healthy. However, which one of these notions is the most fundamental? The relationship between notions is similar to the relationship between modal notions: a person is healthy if he or she does not have a disease and a person is diseased if he is not healthy. Here we say that a person is diseased if he or she has a disease. The characterization shows the complexity of the relationship between health and disease: in this notion, health is the lack of disease – i.e. a person is healthy if for all the diseases in the world a person does not have one of them. This is complicated and cannot as such be of methodological help for medical scientists or clinical practitioners. The reason is that the search for all diseases is not reasonable. However, it never takes place in practice (either in a scientific lab or in clinical practice). This may be helpful in some abstract sense, but does not provide any methodological advice. The notion of health is very complex. It is extremely difficult to put forward a positive characterization of the notion of health. The notion of health is reminiscent in this sense to other, so called, positive notions, such as “human well-being”, “human flourishing”, or “human dignity”. These positive notions appear to be empty in the sense that the characterization of the notion remains very general. Medical doctors need more concrete tools in their clinical practice: the required practical tools can be achieved using the notion of disease as a foundational notion. Each disease has instructions for the treatment of the disease. In fact, Pihlström (2014, 1617) provides a characterization as: We need negative politics because we often ‘recognize what is wrong with something without having a clear idea, or any idea at all, about what is right with it’. This, I take it, is right on the mark. Negative politics, however, is needed not for its own sake but for the sake of a ‘politics of dignity’. This kind of politics addresses, negatively, not how institutions can promote dignity – they can obviously do so in many ways – but rather ‘how to stop humiliation’, that is, how to get rid of violations of dignity. The ‘positive’ notion of dignity itself has little genuinely positive content, and the same holds for the notion of good. (Pihlström 2014, 16-17)

If the notion of disease is taken as foundational, medical care is seen as medical treatment: each disease has a treatment of its own. All this is very welcome: it is important that a medical doctor recognises a disease and can heal the patient. Of course, we may not forget preventive medical care in which people are advised to maintain a healthy way of life. However, this

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also holds the presupposition that health is the lack of disease and hence leading a healthy life means protecting oneself against disease.

Medical science and medical practice Medical science is one of the fields of science. It is subsumed by similar methodological constraints as in all other fields of science. Of course, each field of science has its own methodical constraints which we need not discuss more closely here. As a field of science, medical science intends to achieve new knowledge. The study of medical treatment is part of medical science; of course, medical treatment must be based on medical science. However, medical treatment is not (only) a field of science but is a practical, skills-based activity. What kind of science is medical science? What kind of skills-based activity is medical treatment? These are examples of questions of a philosophical character whose complexity is characterised in Bunge (2013, viii) as follows: The aim of this book is to examine some conceptual issues raised by biomedical research and medical practice. For example, why are the traditional medicines mostly ineffective? Are diseases things (entities) or processes? Why do many medical diagnoses turn out to be wrong? (…) Is evidence-based medical practice as novel as advertised? (…) Are placebo effects purely imaginary? (…) Why has cancer medicine failed? (…) Why do ‘complementary and alternative medicines’ flourish in modern society? And what is to be done about the philosophical schools that deny reality and truth?

The questions are important. However, the presuppositions of the questions may be wrong. Thus, we need to examine the basic ideas behind the questions. It is quite acceptable that philosophical study is basically conceptual. The question about the effectivity of medicine presupposes that we have a good understanding of what effectivity in this case means. Moreover, the first question in the quote above presupposes that “traditional medicines are mostly ineffective”. Of course, to verify or falsify the presupposition is an empirical and not a philosophical task. However, Bunge (2013) analyses the questions and their philosophical presuppositions in a detailed way. For example, Bunge asks about “complementary and alternative medicine”. It is very interesting how the borderline between (mainstream) medicine and “complementary” medicine or between (mainstream) medicine and “alternative” medicine is decided. Obviously, what we characterise as “alternative medicine” is relative to how we identify medical science. It is a historical fact that the

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fields of sciences are historical and cultural entities whose identities change during history. Even if there are clear-cut examples, the specification of borderlines is not a simple task (Lytovka 2014). In medical treatment the question is not only about science but also about medical care and about the patient. The notion of disease is identified within the context of medical science. However, a patient feels himself or herself to be ill. Illness is something the patient emotionally feels: his or her well-being is reduced. However, this is independent of whether he or she has a disease in the sense specified by medical science. Moreover, reduced well-being has been socially recognised when we may speak about sickness.1 It is important to recognise that these notions are independent of each other. This is connected to the rightness or wrongness of the diagnosis which depends on the fundamental character or notions of health and disease. The distinction between medical science and alternative (or complementary) medicine is sensitive to the distinction between notions of illness, sickness, and disease. It is important to recognise that a philosophical study is essentially a conceptual study which may not be identified with a linguistic study. In the philosophy of medicine, we are interested in the proper medical issues, not the expressions of the issue.2 So, it is reasonable to a degree to consider Mael Lemoine’s paper “Defining Disease beyond Conceptual Analysis: An Analysis of Conceptual Analysis in Philosophy of Medicine”. Lemoine (2013, 309) states that the most fundamental task of medical philosophy is to define “health” and “disease”. He differentiates between two schools called “normativists” and “naturalists”, which “share the belief that conceptual analysis is the right procedure for resolving the matter.” So far so good. However, Lemoine (2013, 310) identifies conceptual analysis and the definition of a term. The intention is that definitions “have to determine the logical relations between the terms ‘health’ and ‘disease’” (Lemoine 2013, 310). The characterization of fundamental notions is, of course, the very basic task of any philosophical – and scientific – approach. However, Lemoine’s idea that in the methodology of science explicit definitions of fundamental terms or the field of sciences play a central role, may be somewhat misleading. As Tuomela (1973, 69) says “[i]n the methodology 1

The distinction between illness, sickness, and disease was given by Professor Helen Lambert in her lecture at the International Conference on Medical Humanities in Warsaw (March 10, 2017). 2 The linguistic turn may seem to contradict this. However, linguistic philosophy was interested in the proper subject matter not language as such. See, Rorty 1967.

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and philosophy of science questions of definability of concepts have traditionally occupied a central place”. However, we are not interested in the explicit definitions of the terms “health” and “disease” in a medical theory. In fact, Lemoine (2013) says that the intention of definitions of notions of medical science is to provide the “necessary and sufficient conditions” of notions. This refers to so called “explicit definitions” which in the philosophy of science (and in logic) are understood as relative to a given theory. In fact, Lemoine (2013) refers to the context-dependence of definitions, which implies that he is not just interested in searching for a definition within a given theory but also for a general characterization which can be applied in different contexts, which is a fundamental task in any scientific approach. The philosophy of science in which the search for definitions was one of the most central topics was related to “linguistic” philosophy – i.e. philosophy in which linguistic questions were central. For example, the so called analytic tradition was one of the most central traditions in this linguistic approach. In the analytic tradition, both the logical tradition (Frege, Russell, Carnap) but also natural language philosophy (late Wittgenstein, Austin) can be seen as examples of linguistic philosophy. Linguistic philosophy was quite a general attitude towards philosophy which included logical positivism, analytic philosophy, but also continental philosophy, such as Derrida’s constructionism (Hintikka 2007). The search for linguistic definitions is of course an important task; but it is fundamentally theoretical in nature. However, medical science is not only a theoretical approach; it is also connected to clinical practice and medical treatment. Therefore, the linguistic approach may make a distinction between theory and practice – i.e., separating “medical science” from “clinical practice”. Lemoine (2013) also provides a kind of Socratic method in his search for a definition. For Socrates, definitions were not linguistic or stipulative but real definitions. Real definitions were not only definitions of a given term, but something that provides the real or true characteristics of the thing defined. So, in cases such as health, a definition truthfully says what health is, but also provides a prescription to retrieve health for a diseased person. It is not clear how far Lemoine (2013) follows this kind of Socratic idea, but still his characterizations are of great interest. Boorse (1977; quote from Pörn 2000) characterises the fundamental notional problem as follows: It is a traditional axiom of medicine that health is the absence of disease. What is disease? Anything that is inconsistent with health. If this axiom

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has any content, a better answer can be given. The most fundamental problem in the philosophy of medicine is, I think, is to break the circle with a substantive analysis of either health or disease.

The idea behind the search for definitions is to determine fundamental factors of the field. It is important to rethink and to provide new characterizations of the central notions, as Ranta (2017) shows. We need to know what health is and what disease is; to achieve that goal, these notions cannot be interdependent. The layman may think that the fundamental notion must be “health”: however, it is not easy to give a positive characterization of “health”. It is easier to characterise disease as a fundamental notion and health as the “lack of disease”. Even if we do not know what health is, we know when we lose it. This is also in balance with medical science in which a foundational notion is disease. However, as Bunge (2013) noted, we have to analyse what kind of “thing” is a disease. It is not a trivial task to specify foundational notions of medical sciences even if notions of health and disease could be inter-definable: it may be logically equivalent to characterising a human being either as “healthy” or as “a person who does not have a disease”. However, it is not the same for the person himself or herself, whether he or she is characterised as healthy or as a person who does not have a disease. Health is a central factor of humanity and human well-being, so a disease is a deviation from health. Health is connected to a good life or to the good of man. On this topic, Von Wright (1996, 86) says that it is a topic of “the utmost difficulty” and “[p]erhaps the best I [GHvW] can hope for is that what I say will be interesting enough to be worthy of a refutation”. So, it is not a surprise that, in medical science, efforts are put into the study of diseases with the intention of specifying concrete practical instructions for clinicians. In medical science there is also preventive treatment, which intends to prevent diseases before a patient has them. Moreover, medical clinicians work on behalf of patients and heal them. To have a deeper understanding of the relationship between a medical doctor and the patient, we have to consider the characteristics of medical science and clinical practice. The relationship between a medical doctor and a patient is realised in clinical practice. A clinical practice has a history of its own, and this history has its consequences for present-day practices. There may be different kinds of historical periods identified with their own clinical practices (Engeström 1999). Some of the intellectual framework of clinical practice comes from medical science, which is connected to more general scientific development. The present-day biomedical mainstream has a long history,

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which has some consequences for both clinical practice and caring traditions.

Caring A medical doctor – while carrying on his or her clinical practice – is not a scientist, but a healer who seeks convenient medical treatment for the patient. Of course, medical science is – and must be – a field of science. It is necessary that medical science seeks effective medical treatments and effective (truth-tracking) clinical methods of diagnosis. Such scientific research may refocus its attention from the “person” to the “disease”. It must be emphasised that this is not intended as any kind of “evaluative” characterization, but only to denote the fact that a medical doctor intends to provide current medical treatment for the disease. Current medical treatment is characterised as relative to the disease, not relative to the patient, and for good reason. However, current medical treatment is based on advanced medical science and the mainstream of medical science is biomedical. So, the foundation of current medical treatment is based on biomedical science, as Engeström (1999) has emphasised. This has influenced the intellectual spirit of medical treatment and medical care. It may seem that this is the ideal situation: if someone has cancer, he or she really needs competent medical treatment for cancer. In fact, as Thaler and Sunstein (2008, 207) say, we all “want access to all the best services: doctors, hospitals, prescription drugs”, all of which support the present scientific caring approach. Chochinove (2013, 756) emphasises the need for proper caring: “Despite technical competence, patients and families are less satisfied with medical encounters when caring is lacking.” By “technical competence” Chochinove (2013) refers to science-based skills used to carry out sciencebased medical operations. However, patients also need proper caring and empathy, but it is not easy to embed proper caring into a science-based caring culture. Reich (1995) writes about the “ethics of care”, which forces us to consider the deep historical roots of medical care and medical ethics. There are double traditions of care which may see care as a burden or care as a form of solicitude, and these take on different forms in history. Marcum (2011, 143) characterises these two different kinds of care as: The first type, care 1, represents a natural concern that motivates physicians to help or to act on the behalf of patients, i.e. to care about them. However, this care cannot guarantee the correct technical or right

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ethical action of physicians to meet the bodily and existential need of patients, i.e. to take care of them – care 2.

So, according to Marcum (2011) there is a kind of technical care which supposes sufficient competence in medical science and refers to “evidence-based science” as a foundation for technical caring. However, technically good care is not good enough. The patient is not an object of medical operations but a human being who requires empathy, which supposes the patient-centered care of a “patient’s bodily and existential needs”. These two kinds of care do not contradict each other but are complementary – that is, neither proper technical care nor ethical care alone is good enough. The patient needs science-based care, but at the same time, he or she is in need of contiguity – i.e., that the medical doctor also acts as a decent human and shows empathy towards the patient. The dual nature of care implies dual criteria of competence. Obviously, a medical doctor must have a high degree of knowledge and good skills based on advanced medical science. Following Marcum (2011), this provides a foundation for technical competence. Moreover, a patient needs a healer with empathy: a medical doctor must have skills to show empathy to patients and, following Marcum (2011), this is termed ethical competence. A competent medical scientist may have only technical competence because he/she may not have a strong relationship with patients. In clinical practice, or more general work with patients, the role of ethical competence becomes greater. However, technical competence “refers to an ability to perform or conduct practical and specific protocols and procedures in a correct and an efficient or effective manner” (Marcum 2011, 148) and, as such, it is always the basis of competence; technical competence is very specific, or “discipline specific” as Marcum says. Ethical competence is a more general “humanistic competence” and a generic skill that can be applied within different disciplines. It must be emphasised that “for the professional clinician both technical competence and ethical competence go hand-in-hand” (Marcum 2011, 151). As Peabody (1927) shows, it may happen that “overly scientific” clinicians fail to recognise the patient and his or her suffering. It is important to understand that “a scientist is known, not by his technical processes, but by his intellectual processes” (Peabody 1927). The intellectual process includes ethicality especially for medical clinicians.

Humanity: Action Competence The dual character of a medical clinician’s competence is easy to accept. However, it is not easy to grasp what this means and how to

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uphold the two competences in practice. Technical competence refers to scientific, discipline-specific knowledge and the skills to apply this knowledge in practice – that is, clinical practice presupposes a theoretical basis, but this is not enough. Clinical practice is not only epistemic performance, but also involves face-to-face encounters between the medical doctor and the patient. This is not only a knowledge-based but also an ethical-based encounter, which assumes responsibility, mutual respect and reliability. It is not easy to characterise what this “ethical-based encounter” means; in the clinical room the roles of the medical doctor and the patient are not equal. The medical doctor is the “epistemic authority”; he or she holds superior knowledge about health and about medical treatment. The “face-to-fact encounter” presupposes a reasonable degree of equality, which is related to mutual humanity. In philosophy the classical problem concerning humanity is connected to the relationship between the human mind and body. We do not intend to solve this problem here; it would be absurd to try to solve such a classical philosophical problem. The mindbody problem, in one sense or another, separates the mind from the body. In medical care, human beings should be understood as holistic entities in which the mind and body are in balance, not as a conglomerate of separated parts. We must recognise that when we are speaking about the epistemic authority of medical doctors in questions of health, we are assuming that diseases are something that “happen to the body” and hence the (epistemic) authority may make essential decisions about medical treatment. However, a human being is an “acting agent”. The activity of human beings has been emphasised strongly by Heidegger and other existentialists. However, this idea was not restricted only to existentialists, but was also strongly emphasised by phenomenologists like Brentano and Husserl. Moreover, within analytic traditions, there has been a longstanding practice of analysing human beings as acting agents, as von Wright, Tuomela, Pörn, and Goldman have done. So, the idea that human beings are actors is shared by different schools of philosophy (Toiskallio 2009; von Wright 1996; Tuomela 2000; Pörn 2000; Goldman 1970). Human action is intentional behaviour in which the mind and body work together. The intentionality of an action is an essential factor that refers to the goals (or aims) of the action and to planning how to achieve the goal. Human action is, more or less, a planned activity, as Aristotle noted. The plan includes a specification of the goal and the means intended to achieve the goal. However, human action is not onedimensional with a linear behaviour from a clear plan to a goal via clear

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and effective means, since a human being may have different and competing intentions and goals. He or she must be capable of choosing, integrating and evaluating several goals and means. Choosing, integrating and evaluating are context-dependent and value-laden processes. This is expressed by Pörn (2000, 24) as follows: The kind of agency intended is that of goal-directed action. Such action is a complex set of dynamics in which at least the following phases can be distinguished: goal formation in which the agent settles on new goals or revises old ones; goal integration, another decision process in which the agent forms intentions for the immediate act situation by integrating one or more goals with the circumstances that happen to be obtained in that situation; intentional activity in which the agent translates specific intentions into action; and situation assessment in which the agent evaluates the results attained, reasons for failure or success and the like, and forms value judgements that influence the next round of goal formation. The process exhibiting these phases is intertwined with a cognitive process in which he or she does it.

However, this kind of characterization of action is essentially “technical”. It seems that activity is a consequence of mental processes. Of course, conceptually it is possible to separate planning and intending from proper acting. In fact, a practical syllogism that originates from Aristotle’s philosophy expresses such a separation. However, the way Aristotle formulates this practical syllogism does not include an “inference step” that leads from intentions and beliefs into action, but the actor “immediately starts to act”. It is important to understand that separation is not an easy task. Human activity is a wholly deliberated process which embodies the formal structure of a practical syllogism. Human action is a complicated and confused process in which intentions, plans and actions occur together (von Wright 1996). We need a model that characterises goal-directed action by “the nature of goal formation, goal integration, intentional activity, situation assessment and belief formation, and [it] specifies how all these factors are joined together” (Pörn 2000, 24). However, this is not good enough. We also need a characterization of human action in which human beings themselves are placed centre stage of the whole action process. The agent is not a programmed machine, but an individual who actualises himself or herself and learns about himself or herself: acting means actualising intentions, but, at the same time, it is an individual’s self-realization. The notion of action competence is intended to characterise the close relationship between human activity and human identity; the notion is intended to characterise both the technical and personal aspects of activity.

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Technical aspects are just factors that are included in the practical syllogism, while personal aspects interconnect the actions and the personality (the outer and the inner self). The notion of action competence is of a personal nature. Each person has his or her own action competence, which is not fixed but changes over time. However, an action competence also has an objective aspect; in order to be capable of doing certain actions, an actor has to have some “objective” capabilities. These capabilities are of different kinds: physical, psychological, social, and ethical. It is possible to scientifically study some of the assumed capabilities:3 however, this shows that action competence is also a methodologically interesting notion. It directs the medical treatment keeping the patient at the centre. Hence, the notion of action competence allows us to consider sensitively the distinction between illness and disease. Ethicality is connected to the simple idea that an actor is the cause of all he or she does: by acting, the actor literally causes the results and a certain portion of the consequences of the act (von Wright 1963). The actor is responsible for all of his or her acts and their consequences, and this responsibility is actualised on different levels. First, the actor causes the goal of acting by conceptual reasons. Second, the actor factually causes the (factual) consequences of the act and is responsible for all of these. Sometimes the notion of responsibility is understood factually. However, the responsibility is also ethical: the actor is responsible for the act and its consequences – whether they are good or bad. The ethical responsibility entails guilt: the actor is factually and potentially guilty (Pihlström 2014). Diseases usually reduce the actor’s competence to act, and a medical doctor intends to restore the competence to act. In the best of cases, the competence to act can be completely restored, but unfortunately competence is usually only partially restored. The capacity to be restored can be called resilience, which is essentially a reactive notion. The task of a medical doctor can be understood just as to restore the patient’s action competence, which entails the technical competence of a medical doctor. The notion of action competence deeply characterises a person’s identity. A disease deeply affects the competence to act and hence also the identity of the patient. A medical doctor should also take this aspect of the patient into account, as each patient has an action competence of his or her own. The disease weakens the action competence of the person. It deeply 3

For example, studies on physical action competence (Kyröläinen and Santtila 2010) and on ethical action competence (Toiskallio 2017).

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affects the patient’s inner self; it is not only the objective disease that should be managed. In fact, a patient expects a medical doctor to manage the situation by providing medical drugs or carrying out medical operations which would completely restore their action competence. However, all diseases affect the identity of the patient and make their vulnerabilities known to them: some diseases permanently weaken the action competence of the patient, while some others do not weaken the action competence but may remind the patient that the present state of action competence is not a permanent condition. Moreover, aging and some other changes may have similar consequences. All these may – and usually do – change the personality of the person. A medical doctor has to take seriously the patient’s own action competence and the threats against it. To do this, the medical doctor needs both technical and ethical competence, i.e., empathy and sensitivity. A medical doctor must take the personality of the patient seriously. The action competence offers a concrete context which has both medical and ethical relevance. The two competences are unified within this context, which was expressed by Marcum (2011, 147) as follows: “Although the notion of care or caring has a long history and has defied a precise or consensus definition, caring generally represents a disposition or an attitude in which a person exhibits a deeply felt concern or empathy either for others or even for oneself and then acts accordingly.” The American philosopher Milton Mayeroff provides probably the best-known and most widely discussed definition of care or caring: “To care for another person, in the most significant sense”, according to Mayeroff (1971, 1), “is to help him grow and actualize himself’.”

Closing Words By taking action competence seriously we may balance the competences of the medical doctor and, moreover, the relationship between the medical doctor and the patient. At its best, this allows us to develop a caring culture in which technical and ethical competences are in balance, which entails that a medical doctor does not simply restore the patient or operate on a patient but involves a form of caring which respects human dignity. At the same time, and more importantly, this allows us to develop clinical practices in which human dignity is a fundamental value.

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References Bunge, Mario. 2013. Medical Philosophy: Conceptual Issues in Medicine. Singapore: World Scientific Publishing Co. Pte. Ltd. Chochinov, Harvey Max. 2013. “Dignity in Care: Time to Take Action.” Journal of Pain and Symptom Management, 46(5). Goldman, Alvin I. 1970. A Theory of Human Action. N.J.: Englewood Cliffs. Engeström, Ritva. 1999. Toiminnan moniäänisyys. Helsinki: Helsinki University Press. Kyröläinen, Heikki, and Anttila, Matti (eds.). 2010. “Sotilaiden fyysinen toimintakyky – vaatimukset ja haasteet.” In Mäkinen, Juha and Tuominen Juha (eds.), Toimintakykyä kehittämässä: Jarmo Toiskallion juhlakirja; Military Pedagogical Reflections, 139-148. Helsinki: Maanpuolustuskorkeakoulu. Lemoine, Mael. 2013. “Defining Disease beyond Conceptual Analysis: An Analysis of Conceptual Analysis in Philosophy of Medicine.” Theor. Med. Bioeth. 34: 309-325. Louhiala, Pekka and Stenman, Svante (eds.). 2000. Philosophy Meets Medicine. Helsinki: Helsinki University Press. Lytovka, Michaá. 2014. “The Human Body in Conventional and Alternative Medicines.” Konteksty Spoáeczne, 2014, Tom 4, Number 2: 35-44. Marcum, James A. 2011. “Care and Competence in Medical Practice: Francis Peabody Confronts Jason Posner.” Medicine, Health Care and Philosophy 14: 143-153. Mayeroff, Milton. 1971. On Caring. NY: Harper & Row Publishers. Mutanen, Arto (ed.). 2017. Ethical Basis of Human Security – Towards Renewal of Peace Operations Training. FINCENT Publication series 1/2017. http://urn.fi/URN:ISBN:978-951-25-2928-5. Nordenfelt, Lennart. 2013. “Identification and Classification of Diseases: Fundamental Problem in Medical Ontology and Epistemology.” Studia Philosophica Estonia, 6.2: 6-21. Peabody, Francis W. 1927. “The Care of the Patient,” JAMA 1927, 88(12): 877-882. Pihlström, Sami. 2014. Taking Evil Seriously. Basingstoke, UK: Palgrave Macmillan. Pörn, Ingmar. 2000. “Health and Evaluations.” In Louhiala and Stenman (eds.), Philosophy Meets Medicine, 23-28. Helsinki: Helsinki University Press.

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Ranta, Helena. 2017. “Universality of Human Rights.” In Arto Mutanen (ed.), Ethical Basis of Human Security – Towards Renewal of Peace Operations Training, 96-99. FINCENT Publication series 1/2017. Reich, Warren T. 1995. “History of the Notion of Care.” In Warren Thomas Reich (ed.), Encyclopedia of Bioethics, 319-33. Revised edition, 5 Volumes. New York: Simon & Schuster Macmillan (http://care.georgetown.edu/Classic%20Article.html). Reiss, Julian and Ankeny, Rachel A. 2016. “Philosophy of Medicine.” In Edward N. Zalta (ed.), The Stanford Encyclopedia of Philosophy (Summer 2016 edition), URL . Rorty, Richard (ed.). 1967. The Linguistic Turn: Recent Essays in Philosophical Method. Chicago: University of Chicago Press. Thaler, Richard H., and Sunstein, Cass R. 2008. Nudge: Improving Decisions About Health, Wealth, and Happiness. New Haven: Yale University Press. Toiskallio, Jarmo. 2009. "Toimintakyky sotilaspedagogiikan käsitteenä." In Jarmo Toiskallio & Juha Mäkinen, Sotilaspedagogiikka: sotiluuden ja toimintakyvyn teoriaa ja käytäntöä, Julkaisusarja 1, No. 3/2009. Helsinki: MaanpuolustuskorkeakouluToiskallio, Jarmo. 2017. “From Ethics to Ethical Action Competence.” In Arto Mutanen (ed.), Ethical Basis of Human Security – Towards Renewal of Peace Operations Training, 35-49. FINCENT Publication series 1/2017. Tuomela, Raimo. 2000. Cooperation: A Philosophical Study. Series: Philosophical Studies Series 82. Dordrecht, Boston, London: Kluwer Academic Publishers. Williams, Timothy. 2004. “Past the Linguistic Turn.” In B. Leiter (ed.), The Future for Philosophy. Oxford: Oxford University Press. von Wright, Georg Henrik. 1996. The Varieties of Goodness. Bristol: Thoemmes [originally published in 1963].

CHAPTER TWO UTILIZATION OF GYNAECOLOGICAL CARE AND THE ROLE OF THE GYNAECOLOGIST IN CYTOLOGICAL PREVENTION IN THE LIGHT OF A NATIONWIDE SURVEY IN POLAND WàODZIMIERZ PIĄTKOWSKI AND ANNA DUDKOWSKI-SADOWSKA

Introduction Handbooks on classical Western medical sociology sometimes contain separate subchapters devoted to gynaecological care and the role of women as patients. In these procedures, as late as the turn of the 19th century, a significant role in relationships between doctors-gynaecologists and women patients was played by moral issues, and there were many binding taboos as well as informal but strictly observed rules – e.g. those concerning “treating” the bodies of female patients. The President of the Gynaecological Society in the State of Massachusetts wrote: “I never found it necessary to uncover a patient for a gynaecological examination”. Commenting on the then typical situation, Emily Mumford said: “Most doctors at the time had little understanding of female physiology and anatomy” (1983, 280). Until the late 19th century, the prevailing view in clinical gynaecology was that a large number of women’s diseases were caused by hysteria, psychoses, delusions, and neurasthenia symptoms, and that before starting surgical procedures it was necessary to take measures “to calm down the nerves” of female patients (Mumford 1983, 281). Looking back at the history of gynaecology, its cultural/moral context and the content of professional roles of physicians, a conclusion can be drawn – taking all the obvious differences into consideration – that, even today, the importance of emotional elements such as “attitudes towards a female patient” plays a

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significant role as a factor determining the quality of treatment and the success of therapy resulting in a quick and lasting recovery. We can still speculate about how many stereotypes determined by prejudices, tradition, or morals spread into the patterns of relationships between gynaecologists and their patients during diagnostic processes and in the course of therapy (Hillier 1982, 14). An interesting element that is essential in therapy processes concerning fertility treatment and the sexuality of female patients is the belief that they are “slaves to their hormones” and that “nature”, having predestined them to become pregnant and bear children, gave their psyche “special mental equipment” (Hillier 1982, 155-156). An interesting direction of analyses concerning gynaecology is a discussion on the potential influence exerted by the gender of the treating person (male or female physician) on women’s satisfaction with the quality and effects of interaction during hospitalization. Surveys presented by G. L. Weiss and L. E. Lonnquist show that some female patients prefer women as therapists because the respondents claim that they (doctors) better understand, perceive and interpret their (respondents’) needs and even the body language of the patients; however, empirical studies on factors influencing the quality of treatment and criteria for the selection of therapists indicate various other factors are attributed to “a good doctor”, thus suggesting that gender is not such a significant variable determining choices by female patients (2006, 187).1 It should be stressed that the goals of contemporary studies into gender in the field of medical sociology aim to describe as accurately as possible the effects of situations in which the patient’s gender impacts the way that professional roles are exercised by physicians in clinical medicine (including gynaecology and obstetrics) (Hinote and Wasserman 2017, 204).

Aims The goal of the chapter is to analyse women’s experiences and expectations connected with gynaecological care in Poland, and to discuss the role of the gynaecologist in the prevention of cervical cancer (cytological prevention). Specific issues include: the frequency of, reasons for and feelings associated with gynaecological consultations (including the circumstances of the first visit); the availability and determinants of the use of gynaecological care within public and private systems; satisfaction with the services provided, preferences concerning the person of the 1

See also: Larson Sarfatti, Magali, and Witz, Ann. 2015. “Professional Projects, Class and Gender.” In The Palgrave Handbook of Social Theory in Health, Illness and Medicine, edited by Fran Collyer, 526. New York: Palgrave.

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physician and the reasons for changing the specialist. In reference to earlier decisions stemming from assumptions of the project,2 the study also describes the importance of the gynaecologist as a source of information and motivation for attendance at cytological tests.

Materials and Methods The basis of the results presented is the qualitative studies carried out in the autumn of 2014 as part of the project “The Problem of Attendance of Women to Cytological Tests in Poland. A Sociomedical Analysis.” Computer-assisted personal interviews (CAPI) were conducted at the behest of the authors by the TNS Polska survey agency. The representative random-quota sample of 500 Polish women in the age range 25-59 reflected the structure of the population covered by the Population Program of Prevention and Early Detection of Cervical Cancer. The social-demographic features took into consideration the following factors: age, education, the size of the place of residence, and the professional situation. The interview questionnaire with 82 questions was prepared based on the analysis of 80 qualitative interviews conducted at the first stage of the survey.

Gynaecological Care in Poland – Results of a Nationwide Survey The first visit to a gynaecologist may be an important experience for a woman which will influence her future utilization of gynaecological care. It is worth noting their age and circumstances when Polish women decide 2

The sociomedical research project “The Problem of Attendance of Women to Cytological Tests in Poland. A Sociomedical Analysis” planned 1) to evaluate the actual level of attendance to cytological tests in the population of women covered by such programs (25-59 years), at the same time taking account of analyses conducted as part of the Population Program of Prevention and Early Detection of Cervical Cancer and of other services financed by public funds and the private sector; 2) to describe and interpret women’s attitudes towards cytological tests in order to define their needs in this field; 3) to diagnose the reasons for avoiding (or postponing) cytological tests, taking into account socio-cultural and demographic variables. The project was financed from the National Science Centre funds granted under decision no. DEC-2011/03/B/HS6/04503 and implemented in 20122015. The interdisciplinary team consisted of: Dr Hab. Wáodzimierz Piątkowski, UMCS Professor (Head), Prof. Dr Hab. Wiesáawa Bednarek, MD, Marcin BobiĔski, MD, and Anna Sadowska, MA.

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to consult a gynaecological practitioner: almost half (45%) of 500 respondents were less than 20 years old at the time of the first consultation, and 29% were older. It may be puzzling that one-quarter of respondents (26%) did not remember when they had their first gynaecological appointment, while only one woman never utilised gynaecological care. A large number of the Polish women (32%) had positive emotions and feelings accompanying their first meeting with a gynaecologist. Explicitly negative impressions were shared by 17% of women, but as many as 28% declared mixed emotions: partly positive and negative. It is interesting that, with time, assessments become softened: as many as 47% of Polish women have positive associations with a visit to a gynaecologist, explicitly negative – only 7%, mixed feelings – 21%, and neutral associations – as many as 23%. When asked about the reasons for the first consultation, the respondents most often mentioned: prevention (26%), pregnancy (24%) or routine check-up (23%), which, in view of the character of the first consultation, may have been connected with sexual initiation (before 20 years of age – 43% of respondents, later – 22%). Other reasons included the need to consult a gynaecologist because of oppressive symptoms (14%), persuasion by close relatives/friends (including the mother – 13%), or the intention to use contraception (10%). The last reason was more characteristic of young women (aged 25-29); prevention was listed first of all by the respondents aged 30-40, while pregnancy was the motivation behind the first gynaecological consultation for women living in rural areas and with basic vocational training. The place of residence (p=0.002), age (p=0.001) and the level of education (p=0.000) were also variables that diversified the frequency of gynaecological consultations in the later stages of life (Piątkowski, Sadowska, BobiĔski and Bednarek 2015, 149-165).3 A greater regularity of visits was declared by respondents who lived in urban areas, were in the 30-39 year age range, and had a higher education. The distribution of answers for the entire sample is shown in Chart 1.

3

See also: A different text is devoted to health inequalities, with special emphasis on the utilization of cytological prevention: Piątkowski, Wáodzimierz, Sadowska, Anna, BobiĔski, Marcin, and Bednarek, Wiesáawa. 2015. “NierównoĞci w zdrowiu w Ğwietle wyników projektu Problem zgáaszalnoĞci kobiet na badania cytologiczne w Polsce. Próba diagnozy socjomedycznej” [“Health Inequalities in Light of the Results of the Project: The Problem of Attendance of Women to Cytological Tests in Poland. A Sociomedical Analysis”], Acta Universitatis Lodzensis, Folia Sociologica no. 55: 149-165.

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Chart 1. Frequency of visits to a gynaecologist among the surveyed women (N=499)

Source: Results of the project

The majority of respondents visited a gynaecologist once a year (38%) or more often (16%). A visit once in two years was reported by 17% of respondents; however, as many as 25% had such consultations every three years or less often, which should be considered alarming. The most important reasons for the latest gynaecological visit were similar to those for the first consultation, but the distribution of answers was different: this time the most frequent reasons were routine check-ups (37%), prevention (22%) and pregnancy (12%). The intention to use contraception (7%) or oppressive symptoms (6%) were mentioned less often [Chart 2].

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Chart 2. Reasons for the latest gynaecological consultation among the surveyed women (N=499)

Source: Results of the project

The overwhelming majority of Polish women utilised gynaecological services (Piątkowski and Sadowska 2016, 145-154)4 funded by the National Health Fund (68%), one-fifth (22%) as part of private services, and 4% in both systems. The public system was preferred first of all because of (in answers to open-ended questions): free consultations (33%), confidence in the doctor/satisfaction with previous services (25%), lack of private funds for a private visit (20%) or because of the fact of having public health insurance (“I am insured, I exercise my rights” – 15%). The privately provided services were in turn chosen because of: confidence in the doctor/satisfaction with the doctor (42%), availability of doctors/shorter waiting period (39%), and better quality in the general sense (13%). The list of reasons for utilization of both systems is shown in Table 1.

4

See also: The utilization of medical services (inter alia the services of general practitioners, dentists and other specialists) and the care of health were described with their determinants in: Piątkowski, Wáodzimierz, and Sadowska, Anna. 2016. “Wokóá profilaktyki onkologicznej. Charakterystyka uwarunkowaĔ zachowaĔ zdrowotnych kobiet objĊtych Populacyjnym Programem Profilaktyki I Wczesnego Wykrywania Raka Szyjki Macicy. Communicate z badaĔ” [“On Oncologic Prevention. Description of Determinants of Health Behaviours of Women Covered by the Population Program of Prevention and Early Detection of Cervical Cancer. A Communiqué”], Acta Universitatis Lodzensis, Folia Sociologica, no. 58, 145154.

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Table 1. Specification of reasons for utilization of gynaecological care within the public and private systems

Source: Results of the project

In this context attention should be drawn to the availability of gynaecological care within the public health insurance system. A vast majority of the respondents (91%) knew the location of the nearest public outpatient clinic where they could obtain a gynaecological consultation but “only” 66% of women utilised these services. The other respondents (34%) reported the following reasons for choosing other outpatient clinics: dissatisfaction with the doctor (“the doctor who has consultations there does not meet my expectations” – 24%), a too long waiting period for a visit (23%) and availability of private medical care (23%). Additionally, 9% of respondents said they “had their doctor elsewhere”. A disturbing signal is “lack of confidence in a health care centre”, which was mentioned by 17% of respondents, bad opinions about the doctors working in it (8%) or about the outpatient clinic itself (5%), and finally, poor conditions in the doctors’ offices – (8%). It should be stressed that as many as 77% of respondents reported the distance to the nearest clinic to be under 5 km (32% – under 1 km, 45% – 2-5 km), 14% of the women had to cover a distance of 6 to 10 km, and 7% – more than 10 km. At the same time, a short distance to the health care centre was not significantly conducive to utilising medical services in the public (4%) or private systems (1%). One must remember that Polish women attached the greatest importance to “free visits” (the public system) and confidence in the doctor (the private system). Almost all the respondents (93%) were satisfied with the gynaecological care they utilised when they were surveyed (highly satisfied – 17%, satisfied – 53% and quite satisfied – 23%). Dissatisfied women constituted a small percentage (2%), while 4% admitted that they did not use the services of gynaecologists. Previous consultations with one doctor (14%) were reported first of all by young women aged 25-29

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(29%). In contrast, over half of the respondents (57%) used the services of 2-3 doctors in their adult life, one-fifth (20%) – 4-5 gynaecologists, while 9% of women consulted six or more gynaecologists. Certainly, with age there is a growing likelihood of utilising the services of more than one specialist, but Polish women also indicated specific reasons for changing their doctor – apart from changing their place of residence (29%) or replacement of the doctor in the clinic (5%), which were: the possibility of making an appointment on a convenient date (29%), the wish to consult another specialist (26%), dissatisfaction with the previous doctor’s attitude to the patient (20%), or, finally, dissatisfaction with the gynaecologist’s competency (16%) [Chart 3]. This may show the women’s growing consciousness of their rights, as well as their expectations of the doctor. Chart 3. Reasons for changing the gynaecologist (N=429)

Source: Results of the project

As part of the project, we also analysed the set of features that, according to the respondents, should characterise “a good gynaecologist”. It was an open-ended question, which allowed a selection of the patients’ actual needs associated with the doctor. The most frequent answers were: experience (56%), gentleness (46%), specialist knowledge (45%), politeness (40%), discretion (38%), accuracy (31%), and patience (27%). According to the respondents, the doctor should be also “humane” (24%), communicative (24%), perceptive (15%), caring (12%) and quick-witted (9%). The women had no problems with defining their expectations, which is evidenced by only 1% of respondents who did not answer the question. At the same time, more than half of the respondents (52%) said that the gender of the gynaecologist did not matter, while 45% did not take that

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feature into account. When asked about the preferred gender (N=262), the respondents usually named the female gynaecologist (69%). The foregoing data are a broad context for gynaecological, including cytological, prevention implemented between 2006 and 2015 under the Population Program of Prevention and Early Detection of Cervical Cancer (PPPWWRSM). The majority of respondents admitted that gynaecologists suggested that they could take cytological tests (89%) or other preventive tests and screenings (57%). Health care personnel (doctors, nurses) were also shown as the main source of knowledge on cytology (56%), with overwhelming superiority over other sources like television (26%), brochures and promotional materials (22%), the Internet (21%) or information campaigns (19%). The importance of the gynaecologist in oncologic practice is proved first of all by the fact that it was his/her suggestion that was a real motivation for undergoing cytological tests in the case of 43% of respondents, with a comparatively high percentage of women who took such tests regularly and of their own volition (39%). A personal invitation to a free test offered under the Population Program of Prevention and Early Detection of Cervical Cancer was reported by barely 9% of respondents – just as seldom as a suggestion by a close relative or friend or by the general practitioner. This proves the low effectiveness of such a solution: out of 38% of women who admitted ever having received an invitation to tests and screenings, barely 61% decided to accept it.

The Social Role of the Physician and the Specificity of Gynaecological Practice The issues signalled in the title of our subchapter were of interest from the 1950s to seminal theorists of sociology like Robert Merton, Howard Becker or Anselm Strauss (Merton, Reader and Kendall 1957).5 The subject of research by those authors was, first of all, socialization for the professional role of the physician – how medical students learn both deontological-ethical models and biotechnical content, but also a characteristic medical “subculture”, rites, and traditions that were ubiquitous and had been cultivated at faculties of medicine for years. Those discussions also showed various stereotypes that were widespread in American society, which impacted on young people’s ideas of their future careers: conviction about the strength and omnipotence of the 5

See also: Becker, Howard, Greer, Blanche, Hughes, Everett C., and Strauss Anselm. 1961. Boys in White: Student Culture in Medical School, 239-240. Chicago: Chicago University Press.

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profession, belief in the high quality of conducted research, awareness of the prestige and trust placed by patients in doctors at that time, etc. As perceived by students, medicine therefore appeared as a symbol of rationality, effectiveness, and empirical attitude; it was to be a universal example of the modernization and progress of civilization. These features made up the syndrome of “professional supremacy and dominance” described by sociologists (Blame 1982, 214-215).6 The first more serious changes in perception of the position of the physician in contemporary society began to take place at the end of the twentieth century, when the health care system faced the problem of responding to the demands of anti-medical movements, patient and consumer groups that demanded demedicalization, decentralization and democratization of the institutions responsible for treatment, prevention, and rehabilitation. The context for these processes was the progressive emancipation of large masses of patients who had an increasingly high level of general education, more frequent access to medical websites, greater aspirations, needs and awareness in the sphere of health and illness. These people demanded widespread participation in treatment processes, joint decision-making, and control over therapeutic processes; they declared the need to negotiate decisions concerning treatment processes, and the right to utilise CAM methods, etc. (Riska 2010, 337338).7 The structure and content of the social role of the physician are constantly evolving because medicine is gradually becoming “a medical business” – creating economic interest, organising lobbying groups, and employing specialists and public relations agencies to create new consumer needs, thereby fuelling the growing aspirations of consumers to buy “medicinal products” (Niebrój 2017, 67-68). At the same time, in European societies there is growing criticism of the phenomenon of iatropathogenesis as a feature of practising the profession in question, and pressure is intensifying to subject medicine to a more thorough process of social judgement. All these phenomena result in changes in the process of self-identification of physicians, and there are growing feelings of uncertainty and ambivalence towards the traditional image of the profession and the features of the physicians’ own future careers.

6

See also: Freidson, Eliot. 1970. Profession of Medicine: A Study of the Sociology of Applied Knowledge, 252. New York: Dodd-Mead. 7 See also: Gabe, Jonathan. 2004. “Medicalization.” In Key Concepts in Medical Sociology, 59-63, edited by Jonathan Gabe, and Mary E. Elston. London: Sage Publications.

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In classical Polish medical sociology, discussions on the character of the “professional role of the physician” had already began in the early 1970s: they covered inter alia personality traits, moral qualifications, and specialist competencies that representatives of the profession should have. At the same time, references were made to the ethical canons of science and medicine described by deontologists like W. BiegaĔski or R. Czerwiakowski (TulczyĔski 1976, 514). Norms were also described whose realization would form the foundations of moral authority of medical practitioners. Surveys conducted during that period show that out of 18 features that would characterise this profession, several were indicated most often: these were, inter alia, responsibility, tolerance, ambition, understanding others, and self-control. The ideas of “ordinary people” on the attributes of “a good doctor” usually develop as a result of direct contact during consultations at health care centres or, less often, because of kinship or family connections. Researchers also sought the answer to whether medical universities should educate more doctors trained to exercise roles in the provision of basic health care or prepared to perform tasks fulfilled as part of specialist clinical medicine. This is important for our discussion because the combination of features that make up the notion of an ideal general practitioner and a clinician differs: while in the case of primary care doctors “soft skills” are preferred – i.e. the ability to understand the patient, to feel sympathetic to them, to listen to opinions, as well as commitment to the treatment process –, in the case of clinicians emphasis is laid on professionalism, and biotechnical and instrumental competencies (LatosiĔska 1976, 521). When discussing the physician’s traits, there was consideration of what essentially constitutes the “specificity” of practising this profession, in what respects physicians have to differ in their formal qualifications from experts in other professions, all the more so because, according to many sociologists, the technologization of human work imposes the unification of requirements posed to all employees working in specialised branches of the economy. Opinions were also voiced that the medical profession should now comprise new competencies – e.g. the ability to conduct interdisciplinary research, to think in holistic terms, to combine therapeutic and preventive elements, and to make decisions concerning rehabilitation. It was also pointed out that a consultation with a doctor, especially when occasioned by a severe chronic disease threatening health and life, requires the doctor’s ability to raise the patient’s spirits, reassure and cheer them up; consequently, the scope of this role becomes a

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combination of “technological” and “Samaritan” elements (Sokoáowska 1980, 130). It should be added that the general context for the discussion of factors that make up the professional role of a physician was and is the growing medicalization processes that, despite better and better health indices, cause increasingly large categories of people to become worried about their well-being. This is the result of, inter alia, the operations of commercial medicine that redefine and expand the concept of illness, blur diagnostic criteria, nuance differences between health and illness, and produce the feeling of being threatened by actual or assumed risk factors. The activation of those mechanisms results in a growing demand for a doctor’s services and more and more frequent contact of an increasingly large group of persons with the health care system. A special challenge to present-day doctors is the spread of functional diseases without distinct symptoms and clear diagnostic indications, their aetiology being influenced by difficult-to-define “civilization factors” and subjective states and feelings, which causes additional problems to a physician with negligible behavioural competencies. Consequently, some patients who “subjectively” regard themselves as ill do not obtain a medical certificate confirming their ill health condition, and thereby social acceptance and approval to exclude them from their exercised roles. More and more often the success of therapy, particularly in psychosomatic, chronic diseases and depressions, is also determined by the degree and range of faith in and hope for recovery referred to the qualifications of a given physician; only when the doctor is highly trusted by patients, is the treatment process likely to succeed. The essence of physicians exercising their professional roles and their crucial element is the ability to establish and maintain optimal relationships with the patient. For years, the list of patients’ critical remarks directed at clinicians has been the same: a too superficial way of examination (the stage of making diagnosis and implementing the treatment process), inability to explicitly and intelligibly explain the causes, character and prognosis, and inability to listen to the opinions of patients (Ostrowska 1981, 69). Sociological investigations carried out already during the political-system transformation show that only 1/5 of hospitalised patients were fully satisfied with their contact with a doctor. Medical sociologists agree that the higher the level of patients’ education, the greater is the degree of their “medicine-related competency” and the higher the level of interest in their health, the more they want to perceive a doctor as a partner and advisor in discussions on their joint choice of treatment strategies. Those patients are also interested in their greater

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influence on the treatment procedures applied and in the chances of possibly coordinating and modifying them. In a word, the earlier doctorpatient distance is becoming narrower, and the patient’s position is gradually strengthening, which results in the patients slowly but perceptibly experiencing growing satisfaction with active co-participation in therapy. As has been said above, this picture is influenced not only by new, “pro-patient” regulations adopted within the EU, but also the changing picture of diseases/chronic conditions, gerontological complaints, ailments resulting from social stress, etc. However, could the patient’s growing satisfaction with the quality of treatment be faster and more complete? It certainly could, but an element curbing positive tendencies is the persistent biological-clinical pattern of training at medical schools, which in turn marginalises behavioural sciences and prevents more extensive inclusion of the block of knowledge about the contemporary patient in the mainstream education of medical students, even if the above-mentioned competencies may and should enhance the efficacy of procedures applied in the treatment process. In addition, the progressive corporationization and commercialization of clinical medicine intensify – on the one hand – competition for gaining favour with the patient and striving to satisfy their basic needs (and obtain their money), and on the other hand, the patient is reduced to the role of client while the doctor-patient relationship tends to be formalised, being realised within rigid bureaucratic procedures.

Conclusions We would like to conclude by saying that issues of the “sociology of the medical profession” are one of the classical research subjects that developed within medical sociology from the early 1960s. In this light, changes in the picture of diseases taking place in developed countries cause the elements that make up the professional role of the physician to be complemented with “soft, sociopsychological, competencies” (e.g. the ability to empathise, to reduce the level of stress felt by the patient, qualifications that enable good communication with the sick person, etc.). The type of interaction between the patient and the gynaecologist is thus a special kind of patient-doctor relationship. Such specific elements that accompany this type of diagnostics and therapy – such as feelings of shame, embarrassment, awkwardness and discomfort – require the doctor’s greater emotional involvement in the treatment process. Therefore, we contend that in obligatory procedures applied in contemporary gynaecology, special attention should be paid, because of

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their specificity, to the ability to identify and account for the opinions and suggestions expressed by the patient and to respect his/her dignity and subjectivity, as well as his/her will and due rights.

References Becker, Howard, Greer, Blanche, Hughes, Everett C., and Strauss Anselm. 1961. Boys in White: Student Culture in Medical School, 239-240. Chicago: Chicago University Press. Blame, David. 1982. “Health Profession.” In Patrick Donald, and Graham Scambler (eds.), Sociology as Applied to Medicine, 214-215. London: Bailliere Tindall. Freidson, Eliot. 1970. Profession of Medicine: A Study of the Sociology of Applied Knowledge, 252. New York: Dodd-Mead. Gabe, Jonathan. 2004. “Medicalization.” In Jonathan Gabe, and Mary E. Elston (eds.), Key Concepts in Medical Sociology, 59-63. London: Sage Publications. Hillier Sheila, M. 1982. “Women as Patients and Providers and Sexual Stereotypes in Medical Practice.” In Donald L. Patrick, and Graham Scrambler (eds.), Sociology as Applied to Medicine, 14 and 155-156. London: Macmillan Publishers. Hinote Brian, P., and Wasserman Jason, A. 2017. In Social and Behavioural Science for Health Professionals, 204. Lanham: Rowman & Littlefield. Larson Sarfatti, Magali, and Witz, Ann. 2015. “Professional Projects, Class and Gender.” In Fran Collyer (ed.), The Palgrave Handbook of Social Theory in Health, Illness and Medicine, 526. New York: Palgrave. LatosiĔska, Magdalena. 1976. “Ksztaátowanie siĊ wyobraĪeĔ o zawodzie lekarza u studentów medycyny” [Development of Beliefs on the Profession of Physician in Medical Students]. In Magdalena Sokoáowska, Jacek Hoáówka, and Antonina Ostrowska (eds.), Socjologia a zdrowie [Sociology and Health], 521. Warszawa: PWN. Merton, Robert, Reader, George G., and Kendall, Patricia. 1957. The Student-Physician: Introductory Studies in the Sociology of Medical Education, viii. Cambridge: Harvard University Press. Mumford, Emily. 1983. “Women as Patients.” In Medical Sociology, Patients, Providers and Policies, 280-281. New York: Random House. Niebrój Lesáaw, T. 2017. “Sprzedawcy chorób: etyczne granice stosowania normatywnych definicji zdrowia/choroby” [Sellers of Diseases: Ethical Boundaries to Using Normative Definitions of

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Health/Illness]. In Michaá Nowakowski, and Wáodzimierz Piątkowski (eds.), Procesy medykalizacji we wspóáczesnym spoáeczeĔstwie [Medicalization Processes in Contemporary Society], 67-68. Lublin: Wyd. UMCS. Ostrowska, Antonina. 1981. “Rola lekarza i pacjenta: zmiany w scenariuszu” [The Role of Doctor and Patient: Changes in the Scenario]. Studia Socjologiczne, no. 3/82. Piątkowski, Wáodzimierz, and Sadowska, Anna. 2016. “Wokóá profilaktyki onkologicznej. Charakterystyka uwarunkowaĔ zachowaĔ zdrowotnych kobiet objĊtych Populacyjnym Programem Profilaktyki I Wczesnego Wykrywania Raka Szyjki Macicy. Communicate z badaĔ” [On Oncologic Prevention. Description of Determinants of Health Behaviours of Women Covered by the Population Program of Prevention and Early Detection of Cervical Cancer. A Communiqué]. Acta Universitatis Lodzensis, Folia Sociologica, no. 58: 145-154. Piątkowski, Wáodzimierz, Sadowska, Anna, BobiĔski, Marcin, and Bednarek, Wiesáawa. 2015. “NierównoĞci w zdrowiu w Ğwietle wyników projektu Problem zgáaszalnoĞci kobiet na badania cytologiczne w Polsce. Próba diagnozy socjomedycznej” [Health Inequalities in Light of the Results of the Project The Problem of Attendance of Women to Cytological Tests in Poland. A Sociomedical Analysis]. Acta Universitatis Lodzensis, Folia Sociologica no. 55: 149165. Riska, Elianne. 2010. “Health Professions and Occupations.” In William C. Cockerham (ed.), The New Blackwell Companion to Medical Sociology, 337-338. Chichester: Wiley-Blackwell. Sokoáowska, Magdalena. 1980. Granice Medycyny [Boundaries of Medicine], 130. Warszawa: Wiedza Powszechna. TulczyĔski, Aleksander. 1976. “Poglądy studentów I roku Akademii Medycznej na cechy wzorca osobowego lekarza praktyka” [The Views of First-year Medical University Students on the Features of the Role Model of the Medical Practitioner]. In Magdalena Sokoáowska, Jacek Hoáówka, and Antonina Ostrowska (eds.), Socjologia a zdrowie [Sociology and Health], 514. Warszawa: PWN. Weiss Gregory, L., and Lonnquist Lynne E. 2006. In The Sociology of Health, Healing and Illness, 187, 5th edition. Upper Saddle River: Pearson.

CHAPTER THREE ENEMIES OF THE PEOPLE: JUST WHO IS ENTITLED TO USE EVIDENCE-BASED CRITIQUES OF VACCINATION? STEPHEN WALLACE

Introduction Following the historic opposition to vaccination, which saw A. R. Wallace pen his famous Vaccination submission to Parliament (1889), we have witnessed over the last century a discernibly growing empirical corpus, especially from within the scientific/medical establishment, of critique of this almost universally approved public health nostrum. This paper explores a selection of “insider” critiques, employing a discipline known as science studies – which some consider a useful analytic tool to understand better the progresses and pitfalls of science, and which others consider as an extra-scientific foray (perhaps not even worthy humanity?) into matters more properly left to the authorised cognoscenti. My aim here is to develop a scholarly evaluation of the kinds of responses to some of the above critiques, which may serve as a useful resource for parents and professionals wishing to either undertake or analyse empirical activities concerning vaccination. In view of its public and health-related consequences, vaccination (and other “evidence-based” health interventions in general) remains relatively unexamined in the general public’s consciousness. This type of enquiry also seems to struggle for discursive space in the received or conventional scientific canon, yet such analyses and enquiries have found audiences in the disciplines of science studies and medical humanities (e.g. McKeown 1965, 1980, 1988; Leach & Fairhead 2007; Martin 2013, 2015a, b, 2018a, b). Some of the issues which concern these disciplines obviously involve

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analyses of the politics of science and issues of power, especially as wielded by the many against the few. While the exercise of ideology through peer review and collegiate discipline also emerges in these critiques, I mention them only in passing. But I remain disappointed (but not now surprised) when I consider how rarely this topic arises, even in social studies of science or social studies of knowledge conferences. Medical Humanities has shown a commendable curiosity and breadth of tolerance so far in giving air and space to a range of difficult topics. Yet some arbiters of scientific knowledge still cling to old paradigms, failing to appreciate the preciousness of discursive space for the civil discussion of controversy, such as promised historically by the scientific revolution (See Shapin 1994, 2018), and more recently by Medical Humanities. In a recent Editorial in Medical Humanities Brandy Shillace (2018, 1) explicitly recognises “medical humanities as dialogic encounter – a place for conversation with those outside our own areas of specialty”. She also welcomes the way in which “history informs our present understanding” (ibid.). The controversy I discuss below at some length surely provides a remarkable demonstration of the entanglements (and even mangle?) of the “objectivity of science and the subjectivity of culture” (ibid.). Vaccine supporters still doubt whether any critique of vaccination produced and “examined by scholars in the humanities could claim to have provided that kind of scientific evidence.”1 Presumably they mean any

 1

I intend to show later, that the clamour of (often anonymous or unattributable) critical voices from the angry crowd, such as confronts Dr. Stockmann’s paper (in Act 3 of Ibsen’s Enemy of the People) at the town meeting, is analogous to the universally unreferenced shorthand sideswipes which dominate the anti-Wilyman chatter on the internet fora – even involving otherwise professional writers. So rather than treating such comments as considered contributions to the scientific discourse, I have relegated them to the status of critical social chatter. They can be found in the morass of critique (some extracted from other sites and media outlets) which is readily available on many cyber sites, such as Australian Sceptic, Australian Skeptics (sic), Facebook Page called ‘Judy Wilyman PhD thesis critique’, Science Blogs, Sci Blogs, Stop the Australian Vaccination Network Campaign, Judith Wilyman PhD Controversy Wikipedia Page, Stop the University of Wollongong's Spread of Disease and Death Via Anti-Vaccination PhD, etc. This doesn’t include dozens of press and media reports, organised press releases, professional newsletter comments and other public statements. Despite all this noxious chatter, there remains to this day not one single peer-reviewed scholarly review of Wilyman’s thesis publicly available. One wonders why the editors of the sole professional publication to review Wilyman’s thesis (Durrheim and Jones 2016, 2467-2468) have elected to restrict its access to the public. Perhaps it may be

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evidence about vaccination which might need to be taken seriously. If such interrogations are “more properly the domain of the hard sciences”, then one wonders why there is so little evidence of it in the “internal” professional literature. So I wonder how we can be reassured when medical leaders assure us authoritatively that “the evidence is clear about the safety of vaccines”? So much for Medical Humanities! But given the growing empirical bases of such critical publications, it is perhaps surprising that they have not been addressed more seriously within medical or public health communities. This chapter is one attempt to bring such critiques to a broader and more interested audience. I argue here that vaccination evidence, practice and policy have so far remained strangely2 immune to professional critique, even if there are some indications this may be changing. While the meagre history of vaccination critiques seems to have fallen into a number of disparate categories over the last century, they seem to have attracted differential levels and kinds of defensive manoeuvres. The official history of vaccination-related injury, which has now been institutionalised into medico-government ranks in various constituencies across the world, presents other challenges to the medical orthodoxy. What is surprising is how little official data have been used by vaccination professionals and policy makers alike to improve vaccination practice, following A. R. Wallace. While I make little attempt to evaluate the scientific quality of evidence for or against vaccination policy and practice, I wish to examine the kinds and grounds of critique mounted and marshalled by defending interests, especially evaluating them for symmetry, reflexivity and modesty as advised by (the formidable science warrior and identified enemy of science) Bruno Latour.3 Again I return (see Wallace 2007, 2008) to Ibsen’s classic analysis of scientific conflict in his Enemy of the People as a cogent dramatic doppelgänger for my analysis.

 due to its un-‘scholarly’ farrago of ‘unsubstantiated’, ‘discredited’ (and demonstrably erroneous) claims- all the while arguing for the documentation of the ‘compelling evidence’ requisite for legitimate ‘academic freedom’ and potential falsification. 2 Not so strange when one carefully examines the fate of those committed and courageous enough to publish any (let alone evidenced) critique. 3 Whose most famous works analysed scientific activity “inside” vaccination laboratories, both historic and contemporary (see Latour & Woolgar 1979; Latour 1986).

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This analysis follows some preliminary work I have done in some of the most bitter4 scientific controversies about alcoholism treatments in recent history (Wallace 1999).5 While I remain agnostic6 about the benefits of vaccination, I also approach this topic with considerable commitment to the Mertonian norms of organised scepticism. Having spent much of my life working on scientific controversies, I have attempted to follow Steven Shapin’s (1994, 1996) summative imperative about the need for civility in science. And I have to say that the research for this chapter has reluctantly taught me much about the kinds of errant, toxic, psychopathic behaviour tolerated, and even encouraged, towards some of the critics of vaccination. What is especially surprising is the virulence and breadth of attack suffered by one scholar who documented the inadequacy of any evidentiary imperative for vaccination. She also augmented the critical armoury by documenting the undue and unseemly role of pharma/industry in influencing vaccination policy at research and policy levels. If ever there were to be an “ideal type” or “poster-boy case” for scientific misbehaviour, the responses to vaccination critics may well qualify as exemplars.7

Critical Types Alfred Wallace’s Vaccination: Proved Useless and Dangerous, from Forty-Five years of Registration Statistics (1889) represents perhaps one of the first critiques of vaccination, yet it is curiously overlooked as a valuable epistemic or historic resource. What is astounding about this opus is the clarity with which Wallace lays out problems of vaccination which have recurred ever since. His strictures on founding practice upon statistical evidence are as clear as Thomas Stockmann’s attempt to present



4 The life-and-death controversy about alcoholism treatment which I analysed almost 20 years ago seems almost a “love-in” compared to the response to the Wilyman thesis. 5 Another irony which confronts me, as I write this chapter, is my utter amazement at the level and extent of vitriol, scorn and downright animus to Judith Wilyman and her team at a time of “peace and good will” in the Christian world, while I sit overlooking one of the most beautiful and tranquil rustic scenes in the balmy summer of North Eastern Victoria. 6 But I remain advised by that “self-professed liar” Epimenides, that such professions may not provide much fiduciary warrant. 7 Of course, I am aware of the ancient problem of infinite regress, but don’t see anything unscientific about criticising the critics of the critics of vaccination.

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an empirical paper at the public meeting about the health of the public baths (see Ibsen 1970). His critique of institutional record-keeping and poor methodology should strike a resonant modern chord. He attempts to show his good faith and organised scepticism in vaccination, while at the same time stacking best available data against common practice and belief. He calls for the kinds of comparison studies now much admired by evidence-based medicine to be conducted. He too is aware of the political fight brought on by this kind of allegiance to the soundest evidence. He too suggests that his data show not only a lack of efficacy but evidence of medical harm. And, most of all, he urges compulsion of vaccination to be politically outlawed due to its lack of sufficient empirical warrant, lack of efficacy and documented iatrogenesis. Empirical work over the last century seems to have shown that disease rises and falls have a much greater relationship with other factors such as general health conditions and public health availability (such as fresh clean water and effective sewage facilities) than they do with rates or extents of vaccination. Thomas McKeown is perhaps the best known modern proponent of this critique, but much of his work (see 1965, 1980, 1988) has been consigned to the historic tip of false claims by many medical authorities who still feel the need to dismiss and dismantle his claims. Wallace’s work is considered now to be irrelevant to the modern world (despite being the work of a failed Darwinian agonist!) as it has not been produced by an authorised expert in vaccination. This dismissal is much more difficult in Thomas McKeown’s case, as his credentials as an insider seem impeccable, having held a Professorial post in Medicine at the University of Birmingham from 1945-1977. A most famous case of vaccination critique I mention (but don’t analyse) here concerns the problem of iatrogenesis, particularly as a sideeffect. In 1998 Andrew Wakefield co-published in The Lancet an important empirical piece regarding (MMR) vaccination and gut health which, among other effects, led to Andrew Wakefield’s disciplining, deregistration, and emigration, the retraction of the article by the publishers and a media pursuit, all of which had the aim of besmirching him and discrediting his findings. This program of discredit has remained active since the publication (and The Lancet’s 2010 retraction of the Wakefield et al. 1998 paper), despite a growing body of work now showing even clearer support for the Wakefield thesis. While this critique doesn’t challenge the efficacy of vaccination directly as a public health measure, it demonstrates evidence of harms produced as a collateral effect to vaccination, and argues that the risk/benefit analysis shows the unproblematic endorsement of vaccinations

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to be unwarranted and potentially harmful. Andrew Wakefield’s work is a good example of this kind of critique, as his earlier work especially made very little attempt to oppose the practice of vaccination generally, but proposed a regime of separating the vaccination dose by an active agent (as opposed to the commonly used polyvalent doses commercially available). This empirical work has significant community implications in terms of cost and vaccination availability. A related version of this (iatrogenic) vaccination critique concerns the timing of MMR vaccination, especially for infants. In 2004 a team of researchers connected to the CDC published a paper in Pediatrics which has become the subject of much interest and revision. While there are many significant issues arising out of the conduct of this paper, most of which I will not discuss here, the importance of timing, especially for some identified ethnic groups and genders, remains contested in the swathe of claims, counterclaims and accusations. In spectacular fashion, one of the authors of the 2004 paper, William Thompson, provided some background information documenting some empirical misbehaviour occurring in the published works of his employer, the CDC in the USA. He purportedly provided evidence for another paper being prepared by Brian Hooker which was published in 2014 and then withdrawn – à la Andrew Wakefield. This correspondence formed some of the background for Andrew Wakefield’s loved and hated film Vaxxed, which has had a second recent instalment. This 2004 paper then formed the centrepiece of the more serious critique of vaccination (especially policy making): the ethical problem of withholding and falsifying empirical evidence on vaccination. Whereas the widespread and extreme reaction to Andrew Wakefield’s papers invoked all manner of inculpations of fraud, misrepresentation and scientific misbehaviour, the reaction to an allegation of misbehaviour by the CDC as claimed by William Thompson received very little public attention and subsequent calls for corrective action. William Thompson’s story directly addresses this problem even though he seems to have subsequently amended his critique, all the while continuing his long and valued service in the CDC. His initial disclosures (to Brian Hooker) concerning CDC publications8 seemed to indicate a basic level of scientific fraud or misbehaviours in reporting and manipulating data on vaccination studies. But on September 13, 2018, the scientific world was shocked to hear that Peter Gotzsche, one of the governing and founding members of the prestigious and trusted Cochrane Review Group was fired for co-

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Which themselves addressed the covariates of timing, age, gender and race.

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publishing against the Cochrane review of HPV vaccination, which omitted several important data sets. While this is probably the biggest shakeup ever to occur in evidence-based medicine, it is markedly important in the corpus of vaccination critique. His firing from his own Hospital in Denmark on October 29 came as an even greater surprise to him. Suffice it to say he is not happy and has no intention of going quietly. In this chapter, however, I concentrate on a specific episode which concerns two specific types of vaccination critique: one concerning an evidentiary hiatus due to “undone science” (which I call “Cochrane deficiency syndrome”); and the other concerning undue extra-scientific influence on decision-making in vaccination science; or “interested” influence on vaccination policy. A particularly spectacular example of both these critiques has arisen recently with the Doctoral work of an Australian university student who attempted to develop a contemporary informed critique of Australian vaccine policy (Wilyman 2015), along the lines of a traditional study of science (whether medical science or humanity?). While it would be foolish of me to try to discuss the inordinate amount of data and scholarship immanent in this text, I simply wish to summarise and review some of the critiques of this work especially as they resemble and reproduce other kinds of critiques aimed at other critics of vaccination.

Popular Enemies While most people are aware of the cogent use of the Socratic dialogues in developing reliable knowledge about the natural world, few are aware that another of the patron saints of the Enlightenment used a similar dramaturgical approach (aided by but not based upon mathematical exposition and proof) in teaching the new physical sciences of kinematics and strength of materials, etc. Galileo’s Two New Sciences (1974) provides a rich and compelling example of the use of “humanity-based” methods to reach profound understandings of the physical world in 1632. While Galileo’s characters were drawn from dominant philosophical positions of the time, his dramatic use of irony and humour reveals the value of this approach. It is perhaps no accident that both these paradigm makers were seen by some at some stages as consummate enemies of the people.9 But like the modernist drama of Ibsen, it is almost impossible to admire the accomplishments of the modern world without acknowledging their

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Like Jenner and Pasteur, at least initially; and for much better reasons.

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unique and enduring contributions, despite the public opposition they had to endure. So it was with Ibsen, who (on the dawn of Pasteur’s germ theory, and in anticipation of Koch’s postulates) produced one of the finest and perhaps earliest treatises on dissent in conventional science in 1862. Ibsen had trained as an apothecary in 1844 and attempted to study medicine in 1850, just years before Pasteur’s famous studies, which themselves have become the subject of ethical/epistemic critique by the eminent scholar of science Gerard Geison (1995). Ibsen was an unqualified supporter of the modern project, especially as it concerned medicine, but curiously he sketched the problem of internalist critique possibly better than anyone before or since. As a medical humanities resource it has proven most useful in the professional education of medical professionals (See Wallace 2006; 2007) It is in the first ten pages of Ibsen’s Enemy of the People (op. cit.) that we learn of town physician Thomas Stockmann’s cautionary approach to publishing evidence about the health of the town baths. It seems he had concerns about this civic asset some months before, but has awaited more definite proof from the new sciences before he is willing to share his concerns, despite some encouragement from the media. He takes some pride from his sponsorship of this balneo-therapeutic intervention (which was popular at the time of publication), so his commitment to and investment in it are unquestioned. The financial and commercial value and interests of this spa to the town are explicitly recognised by all the protagonists early in this Act, and despite some adumbrations of conflict between the Mayor’s brother (Peter) and the physician’s brother (Thomas), it seems all actants are unproblematically committed to the continuance of the baths and the maintenance of the health of the town citizens, and the visitors who flock to the town seeking its health producing spa and enhancing the wealth of civic coffers. When the bad histological news from the laboratory finally arrives, Dr. Stockmann celebrates his “great discovery” with his family, especially as it confirms his hypothesis of concern expressed over a year ago – on the basis of his clinical observations and practice. At that time he had hypothesized an exogenous cause of the observed illnesses from the baths. Stockmann exposits the general and so-far unquestionable consensus that the town baths are prophylactic or health-producing, and his own role in promulgating such a view. He then announces a volte face which is received by family and media with some dismay and opposition: the spa is a “pesthole” which is contaminated by upstream industrial pollution. He lays out his scientific evidence, which has now been confirmed by “strict

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laboratory analysis” at the university; his irrefutable proof of causation is the “millions of bacteria” now observed by certified scientists. He explains that his previous concerns were withheld until he had absolute proof in his hand. His commitment to confidentiality is explicitly tested by his wife who asks why “the family” was not the first to know. Dr. Stockmann is well aware of his outsider status in the community, but imagines that his discovery will enshrine his status as a valued community member. While all this smacks a little of the traditional Greek tragedy, Thomas Stockmann shows very little evidence of the fatal hubris which will ensure his demise. It turns out that Stockmann’s concerns about (and preventative ideas for) the baths were dismissed at the time of their construction. By the close of Act One, Dr. Stockmann enthusiastically determines now to publish his findings, and insists modestly that he is only doing his civic duty – nothing more or less! This precedes the drama to follow. In short, the motives of the qualified and informed critic are to be tested in every possible tribunal of reason, and the results are dystopic – especially if the critic is right. The contest is not new, but the terms of engagement are distinctly of the modern biomedical world that Ibsen is foreshadowing. What becomes evident by Act Four of Enemy of the People is that the media, initially allies of the respected physician in the town have now shifted to allying themselves to the interests of the powerful in the town and consequently now redirect their critique towards Thomas Stockmann with all the resources and odium they can marshal. This part of Ibsen’s story replicates the most recent phase of the Judith Wilyman affair (as it has come to be known), as the media have rarely (and advisedly) never shown much interest or enthusiasm in even reporting anything which might be seen to seriously challenge the most central tenets of the medical canon. At best, the media exercise and justify their gate-keeping role by exposing and aiding the removal of bad apples: this stratagem has the coterminous effect of serving to validate the general health of the master’s orchards.

Undoing Vaccination Science Vaccination history certainly lays the critical precedents for Wilyman’s critique with the passing of the 1871 Vaccine Act which mandated vaccination for the poor in the UK some eighteen years BEFORE the Vaccine Commission was founded (in 1889) to establish the safety and efficacy of vaccination as a condition for its mandating!!! Some vaccination critics are still resolutely old-fashioned enough to demand

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proof of efficacy antecedent10 to the implementation of widespread vaccination to avoid the problem of “recovery-led interventions” which have become so popular in western political circles. And so, the first vaccination resistance group in the UK (the AntiCompulsory vaccination League) was established soon after the Act in 1871, and has become the first in a long line of community-based activist groups (aided and abetted by scholars like Alfred Wallace) attempting to influence government policy about scientific matters. Over the last century there have been harrowing catalogues of what might be called anecdotal accounts and narratives of vaccination related injury, now represented by the daily memorials placed by grieving parents on a variety of electronic platforms and media like Facebook (See Leach & Fairhead 2007). While these critiques were well-known among cognoscenti, it wasn’t until 2016, when a female scholar successfully completed doctoral work on vaccination policy in Australia that a serious and substantive work of scholarship became the target and subject of the most extraordinary and unprecedented hostility and critique; this has come to be known as the Wilyman Affair. Whereas the critiques of Andrew Wakefield and William Thompson arose from publications in canonical medical journals, the vicious and extreme reaction to Judith Wilyman's analysis may have arisen from the fact that her analysis was considered outside the conventional vaccination discourse, and the perception that the author (and her team) was ill-equipped for any such analysis. While it might surprise some that public outrage was so easily primed in 2016, the general reaction to anything vaguely anti-vaccination in Australia still provokes almost blind rage and refusal to discuss. The awarding of Judith Wilyman's doctorate stimulated public outrage from many quarters, directed at the doctoral student, her supervisor and the awarding institution. While the critique has made no substantive claims of fraud or misbehaviour (and indeed this has never been suggested or evidenced), it may be that the conclusions of the accredited dissertation might be seen as a reductio strategy to falsify assumptions of the vaccination industry/palliative; a public health intervention which is way too important to require supportive scientific evidence, or even be subject to any scientific critique. It can be seen, even from this preliminary and superficial analysis that reactions to the exposés have hardly been symmetrical or evidence-based. Rather than being received as academic works of a disinterested empirical

 10

A not unreasonable request in line with Koch’s famous postulates.

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nature, they have all been characterised as examples of (at best) the ignorance, and (at worst), the bad faith of the anti-vaccination crowd. What is especially curious given the differential level of odium projected at each of these vaccination critics is their critical positioning. While Andrew Wakefield’s work showed links between MMR vaccination and autistic spectrum disorder and gut inflammation, William Thompson’s advice seems to suggest that links between autism and vaccination had been deliberately altered and biased by government guardians of vaccine safety at the highest level. Interestingly, Judith Wilyman came under most fire for suggesting that vaccination policy was underpinned by too little empirical evidence – “undone science”, and too influenced by industrial/pharmaceutical interests. While I suspect each of these documents has been shown to pass most conventional trials of empirical/scientific adequacy, there has been little attempt aside from ad hominem attacks to refute or replicate the results or show their methodological inadequacy.

Never Enough...Evidence It becomes a difficult task to address the entire plethora of critiques of Judith Wilyman as they have mainly been published in popular media, using language which I find anodyne in learned circles. While I would endeavour to write my own critiques after reading the entire documents I am critiquing, I am at least slightly encouraged by the critic who couldn’t find time “to read it all. I don't know that I really need to, anyway, if what I've read thus far is any indication” (See FN 1). I was also encouraged, after reading the constellation of attacks on Judith Wilyman to note that this critic could manage to find one solitary virtue: “In fact, the only areas where the examiner felt Wilyman had met with relevant standards were that it was presented in a manner and level appropriate to the field of research and that the literary standard was adequate. In other words, it met basic standards of presentation” (see FN1). Leaving this sole merit to one side, most published critique, which seems remarkably organised and univocal, seems to claim that the fault lines of Judith Wilyman's work fall under a number of broad categories: the candidate, the supervisor, the examining team, the awarding institution, various components of the document, and social responsibility. Taking each in turn, the critiques of the candidate hardly form any kind of critique I recognise, in any formal academic forum, and rather resemble a farrago of ad hominem attacks. They include the charges that Judith Wilyman is a “well established antivaxer”, an “antivaccine loon” and a

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“marginal quack” (see FN1). More seriously the claim that she was a “grossly unsuitable candidate for doctorate level study” sits rather badly with another critic’s suggestion that her thesis was “definitely not worthy of achieving PhD status, and was more in line with a Master’s degree level” (see FN1). Despite her Master’s degree in Public Health, she has “no indication of a broad understanding of the discipline, and has no right to ‘claim to be an expert in public health’.” Most serious was the curious (and misinformed) charge that there was “no evidence that Wilyman ... conducted original research” (see FN1). It was also suggested that her academic comportment was not one of scholarly disinterest resulting in her being “not willing to entertain evidence”, perhaps understandable given her “entrenched ideological position”, and “pre-determined conclusions”. The serious topic of “interested shaping” of research and policy was waved away with summative disdain that the text was marred by “conspiracy theories, with no data to support the conclusions” and all kinds of un-evidenced assertions about “underhand shenanigans” in the vaccination industry. One medical spokesperson characterised it as “a thesis that’s talking about the science of medicine without any support of its argument from credible scientific literature” (see FN1). In a similar vein, the charges against her supervisor strike me as even more egregious. Her principal supervisor, Brian Martin, is described as “slightly rogue” and “sympathetic to medical cranks”. While I find this a disingenuous way to describe an outstanding career in professional academia instantiating a range and long history of detailed studies of controversy, the claim that he may not have “sufficient knowledge to supervise the thesis” ignores his initial training in physics and impressive publication list in peer-reviewed journals on the very topic of vaccination. Again, the charge that Judith Wilyman conducted her work without “any apparent scientific oversight” seems to defy any reasonable analysis. And the portmanteau claim of “manifestly inadequate supervision” is difficult to address, given all the above (see FN1). The examiners are dealt a much more mixed review, which seems to confound their critiques. Despite being “handpicked”, lacking “necessary credentials”, and being “out of their depth”, it appears, paradoxically, that one of the initial examiners assessed the work as requiring major revision to fulfil the necessary requirements, thus necessitating the routine engagement of a third examiner. Further it is claimed that any study which appears to be “cross-disciplinary in a way that need(s) input from another department should not be examined by a Humanities department” (see FN1).

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Wollongong University is spared none of the blame as it “saw fit to bestow a PhD” on her which purportedly demonstrates its “lackadaisical attitude to academic rigour” (see FN1). The advice from one critic is that “somebody needs to be assessing the accuracy and rigour of the scientific analysis provided, during both the supervision and examination processes, so that no further ‘PhD by stealth’ makes it through the academic portals” (see FN1). In granting Judith Wilyman her doctorate, despite an unusually critical set of demands and reviews, Wollongong has brought a lasting ‘stain upon the university’.” (see FN1) The largest corpus of critique, perhaps expectedly, concerns the thesis document itself. And so it goes on, at an even more fevered pitch. Apparently, and not surprisingly, the dissertation is “not suitable for publication” as it makes “no significant contribution to the knowledge of the subject”. This may not be surprising if one accepts that it demonstrates, maybe even embodies, exemplary “academic overreach”, “outside its area of expertise”. A snide shot is taken at the disciplinary structure in the comment that an “abstract for a thesis in humanities (and any other academic discipline) needs to include a statement of purpose”. So it may follow that it suffers also from a “lack of an appropriate theoretical framework”. Again the charges that the document demonstrates a “glaring lack of understanding of immunology and vaccine science” that is explainable by “serious concerns about a lack of engagement with existing literature” and “no mention of any of the vast scientific literature that includes large clinical and epidemiological studies – or attempt a(t) critique”. Accordingly, her document is adjudged as a “junk thesis”, “just a rant” full of “pseudoscientific tripe”. Her mere “repetition of antivaccine tropes” constitutes nothing more than a “litany of deceitful reveries” (see FN1). But perhaps more gravely in the academic world-view are the “serious errors and misrepresentations” and “easily refutable downright incorrect information” which supposedly permeate her work. Examples included the “resurrection of the long-discredited link between vaccines and autism” (see FN1). While I consider it entirely appropriate to evaluate a higher degree document by its choice and use of relevant, historic and up-to-date references, I don’t recognise Judith Wilyman’s bibliography as populated by “bottom dwelling literature that includes 50-year-old discussions”, “out-of-date references” which constituted no more than a “who’s who of the global anti-vaccination junk science” – or at least a compendium of “thoroughly debunked pseudoscience”. Her “highly selective and poorly

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informed review” also contained one example of “alarming omission for a paper on immunisation” (see FN1). Finally, she was brought to task for her academic and professional irresponsibility for being “on the wrong side in a ‘battle of life and death’.” Yet if her main theses were to be proven correct, or even supportable, this may “lead to lower levels of vaccination.”

...ultimum non nocere So we arrive at the close of Act IV of Enemy of the People. Thomas Stockmann has used his expertise to alert his beloved town of the “enemy” within their midst – their golden goose of healing baths. And their response to his loyalty against all odds – to be dismissed as an enemy, discredited as a professional, and attacked by its foot-soldiers. This is the thanks Thomas Stockmann gets for exercising his finest personal, professional and civic motivations. The massive amount of criticism that Wilyman’s thesis has received online proves to be a nice modern analogue for the town meeting which Stockmann tried to address: calls for protocols, mindless excoriations, fanfares to traditional values, procedures to gag, and motive questioning. Both Thomas Stockmann and Judith Wilyman have enfolded political messages which are even more unpalatable to their audiences than the empirical ones. But at their core is a common modern call to on-going empiricism at the heart (and head) of reliable knowledge. Both directly confront received consensual knowledge as problematic, especially as a warrant to refuse any revision. And all the while the media plead their own innocence (of partiality and self-interest) as they conspire and collaborate with whatever the daily consensus requires. They show their grubby hands as they dissimulate and weasel their way through Machiavellian strategies designed only to situate themselves from beyond contempt to beyond reproach. Central to both critiques is the notion that the “problem” is internal to the current politic-epistemic apparatus – and that the current apparatus requires radical re-configuring to solve the “problem”. “Solutions” or “cures” may require apparatus found outside, and even hostile to the current configuration. The pestilence is coming from within the community’s most relied-upon and trusted resources, which are economic at their heart. Threats are recognised and re-delivered with serious intent, and now, even the act of critique means the community will never be the same. Forgiveness is not an option, and division, contumely, and

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outcasting are thus requisite – even desirable. Ibsen’s warnings are stark – and prescient it seems. All this, 150 years before Judith Wilyman completed her doctorate questioning vaccine policy in Australia, Thomas Stockmann and his family decide to move before they are run out of town. Again resonances of Andrew Wakefield’s treatment should alert us to the costs of “vax shaming”. There is much in these stories to appal and shame – much criticism to be framed, targeted and delivered. Some of the terms commonly, and almost instinctively, used in this discourse are anything but adult and professional. If ever there was need for medical humanity, this may be it. One reason for the intensity and acerbity of the reaction to one antivaccination critique may be explained by the disciplinary approach. While medicine always qualifies as a “human” and humane approach to health and illness, other sciences and humanities may not be so “man centric”. It may be well beyond the pale to suggest that “primum non nocere” might be breached, not only in its observance, but by the failure of its highest priests to recognise harm caused at their benevolent hands by their failures to observe. Obviously, any rogue member (Stockmann) who calls out any clergy and pontificate, may be subject to the harshest intra-mural sanctions (see Andrew Wakefield). It follows that only the more egregious breach and blasphemy of the canon could come from infidels, who purport to use the sacred tool to dismantle the master’s house.

Conclusion What is at stake here is also the question of what qualifies as a “science” and the corollary question: who is then entitled to practise science, other than scientists? But some things/industries/policies/ interventions may be just too important to be slowed down/constrained/ decided by difficult, complex, equivocal and protracted evidentiary resources which constitute their warrant. One may not need to understand the sufficient titres of antibodies required for protection against identified strains of HPV to appreciate what a vaccination expert, who has been fired for speaking out against his organization’s role in data contamination, is explicitly saying about vaccination and its evidentiary precariat. The systematic, collusive and extra-scientific responses of the “entitled” (internal) guardians of vaccination, have attempted to create a public imaginary of holy wars in which the enemies of the

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people/science/good intentions must be identified, labelled and terminated with extreme prejudice. Perhaps the burning of their publications is one so-far unheralded atrocity to follow. Whereas the rhetorical sin of “ad hominem” often signalled the failure of scientific advantage in discursive terms, the scandalous and pernicious attempts to disqualify, discredit and dismiss the evidence collected by critics of vaccination reveal a grubby and malign convergence of (self) interests, rather than, as intended, the misguided and ill-informed extra-disciplinary musings of the otherwise unemployable. One might now be very convinced of the folly and futility of attempting any serious or evidence-based critique of vaccination. Yet one might still ask who might or should be charged, in the current set of political arrangements, with the task of voicing any authoritative critique of vaccination. Meanwhile the invisible and visible colleges bulwarking this universal palliative remain fairly comfortable and relaxed (even invulnerable) about the infallibility of their first-line nostrum, enjoying their dominant position as a potent blend of government, professional and industry interests. So it may well remain the mission of only a very small (probably diminishing) and brave (foolish?) cadre of scholars, presumably a little further removed from the huge honey-pot of institutional rewards, who elect to challenge this behemoth. Why should they expect to be treated otherwise? The Lysenko syndrome seems to be alive and thriving within the medical and health sciences (Carey 1977). But the inexorable and dystopic conclusion of this chapter is that those charged with the scientific responsibility and resources for on-going disinterested investigations of such an important topic – the mandatory delivery of a health intervention with at least a questionable safety and efficacy record, into the bodies of the healthy (often under-age and thereby legally incompetent) citizens of a self-professed liberal democracy – seem unwilling to do the hard work and ask the hard questions. They are certainly entitled – some might say professionally obligated – to do this for all sorts of reasons. What they are not entitled to do, and should face the harshest professional disciplinary sanctions available for doing – is attempt to stop, vilify, discredit (and even persecute) those who, by reason of professional qualifications, or academic area of study, elect to do what Everett Hughes long ago called the “dirty work” of asking the Emperor to cover his immodesty (Hughes 1962).

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Acknowledgement I would like to thank Brian Martin, and especially the anonymous reviewers, who have helped me improve this paper. It has not been at an easy time of my life, and many times the project looked insuperably difficult and anodyne.

References Carey, Alex. 1977. “The Lysenko Syndrome in Western Social Science.” Australian Psychologist, Volume 12, Number 1: 27-38. DeStefano, F., Bhasin, T. K., Thompson, W. W., Yeargin-Allsopp, M., and Boyle, C. 2004 “Age at First Measles-mumps-rubella Vaccination in Children with Autism and School-matched Control Subjects: a Population-based Study in Metropolitan Atlanta." Pediatrics Feb. 113(2): 259-66. Durrheim, D.N. and A.L. Jones. 2016. Public Health and the Necessary Limits of Academic Freedom. Vaccine Vol. 34, Issue 22: 2467-2468. Editors of The Lancet. 2010. “Retraction Ileal-lymphoid-nodular Hyperplasia, Non-specific Colitis, and Pervasive Developmental Disorder in Children.” The Lancet, Vol. 375, Issue 9713: 445. Galileo, G. 1974. Two New Sciences, translated by Drake Stillman. Wisconsin: University of Wisconsin Press. Geison, Gerald L. 1995 The Private Science of Louis Pasteur. Princeton, NJ: Princeton University Press. Hughes, Everett C. 1962. “Good People and Dirty Work.” Social Problems 10: 3-11. Ibsen, Henrich. 1970. Ibsen Four Major Plays Vol 2. NY: New American Library. Latour, Bruno and Woolgar, Steven. 1986. Laboratory Life: The Construction of Scientific Facts. Princeton: Princeton University Press. Latour, Bruno. 1988. The Pasteurization of France, (translated by Alan Sheridan and John Law. Cambridge, Massachusetts: Harvard University Press. Leach, Melissa and James Fairhead. 2007. Vaccine Anxieties: Global Science, Child Health and Society. London: Earthscan. Martin, Brian. 2013. “When Public Health Debates Become Abusive.” Social Medicine, Vol. 7, No. 2: 90-97. —. 2015. “On the Suppression of Vaccination Dissent.” Science & Engineering Ethics, Vol. 21, No. 1: 143-157.

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—. 2015. “Censorship and Free Speech in Scientific Controversies.” Science and Public Policy, Vol. 42, No. 3. —. 2018a. “Evidence-based Campaigning.” Archives of Public Health, Vol. 76, article 54. —. 2018b. Vaccination Panic in Australia. Sweden: Irene Publishing. McKeown, Thomas. 1965. Medicine in Modern Society. Medical Planning Based on Evaluation of Medical Achievement. London: George Allen & Unwin. —. 1980. The Role of Medicine: Dream, Mirage, or Nemesis? Princeton: Princeton University Press. —. 1988. The Origins of Human Disease. Oxford: Basil Blackwell. Schillace, Brandy. 2018. (Editorial) “Border Crossings: Joining a Multidisciplinary Conversation about Medical Humanities.” Medical Humanities 44: 1. Shapin, Steven. 1994. A Social History of Truth: Civility and Science in Seventeenth-century England. Chicago: University of Chicago Press. —. 2018. The Scientific Revolution, second edition. Chicago: University of Chicago Press. Wakefield, A. J., Murch, S. H., Anthony, A., Linnell, J., Casson, D. M., Malik, M. et al. 1998. “Ileal-lymphoid-nodular Hyperplasia, Nonspecific colitis, and Pervasive Developmental Disorder in Children.” The Lancet 351: 637-41. Wallace, Alfred R. 1899. Vaccination Proved Useless and Dangerous: from Forty-five Years of Registration Statistics, second edition. London: Allen. Wallace, Stephen. 1999. “Controlling Alcoholism: Technologies of Trust in a Struggle for Scientific Authority” (unpublished thesis). University of Melbourne, Melbourne. —. 2007. The Culture of Evidence. Annual Social History of Medicine Conference, Exeter University. —. 2008. “Governing Humanity.” The Journal of Medical Humanities 29.1: 27-32. Wilyman, Judith. 2015. “A Critical Analysis of the Australian Government’s Rationale for its Vaccination Policy” (unpublished thesis). University of Wollongong, Wollongong.



PART 2 DEFINING MEDICAL SPACE

CHAPTER FOUR AN INTRODUCTION TO THE STUDY OF “SURGICAL THEATRICS” CYNTHIA J. AVILA

Sorry indeed should I be, to sport with the life of a fellow-creature who might repose a confidence either in my surgical knowledge or in my humanity; and I should be equally disposed to consider myself culpable, if I did not make every possible effort to save a person whose death was rendered inevitable, if a disease were suffered to continue which it was possible for surgery to relieve. In the performance of our duty one feeling should direct us; the case we should consider as our own and we should ask ourselves, whether, placed under similar circumstances, we should submit to the pain and danger we are about to inflict. Astley Paston Cooper and Benjamin Travers, Surgical Essays, Part 1 (1818), 111–112.1

Far beneath the inpatient wards, a scrubbed ensemble of nurses, technicians, physician’s assistants, and anaesthesiologists prepare for a drama that unfolds on the surgeon’s stage. It is here amongst a ceaseless motion that our patient lies, ready to be probed with tools which serve as essential props to the physician’s care. Unconscious, she is privy to the unnatural; a stark absence of relativity radiating beneath the incandescent lights. Surely this is bound to be a good story, because as we all know (and often wish to forget), nothing in the operating room – including the patient’s life – is certain. Perhaps as a result of this inherent drama, it is not surprising that operating rooms were once called operating theatres (Wangensteen 1975). Until the 1900s this nomenclature held true, originating from the wonder that is inseparable from surgery; that is, the fundamental curiousness in dissecting a living human being. It is this curiousness that makes surgery a

 1

Brown 2017.

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dramatic enterprise – for although there exists a possibility that the patient will live, so too exists the very real possibility that the patient will die. The patient’s life therefore depends on the surgeon, who acts as the protagonist – the potential hero or executioner, a “tour de force” – in our story. In his account of a surgical procedure in the early 1900s, Dr. Fredrick Treves (1853-1923) describes his perception of a surgical proceeding as follows: “[the surgeon] stepped into the arena of the operating theatre as a matador strides into the ring. Around him was a gaping audience and before him a victim, quivering, terror stricken, and palsied with expectation” (Alpert 2014).2 It is here, within the walls of an operating theatre, that the spotlight shines on the surgeon and the spectacle inherent to his work. The early characterization of the operation as theatrical reflected an amphitheatric space in which institutionalized surgery originated. In Europe and the United States, several renditions of the operating theatre were built to include seating for more than fifty viewers, allowing audience members to observe, smell, and hear the surgeon (and patient) in real time. This seating area was elevated incrementally – a signature of the amphitheatric design – and permitted spectators a view of the patient, the medical team, and the tools placed on the instruments table. The audience included colleagues, faculty, medical students and, in earlier presentations, even the general public. This assortment of attendees may seem surprising at first, but what occurred within the operating theatre could no doubt provide scholarship and an unrivalled, mysterious form of entertainment for all (Wangensteen 1975). Despite popular attendance of these performances, spectatorship dramatically decreased with the discovery of Germ Theory and acceptance that public surgeries contributed to patient post-operative infection (Tait 1887). As a result, operating theatres were remodelled to become an exclusive and sterile space distinctive of operating rooms. In parallel with this transformation, the surgeon’s work became a more calculated and evidence-based practice, where clinical decision-making and research, as opposed to procedural familiarity or expertise, prevailed. According to Rebecca Barry, the author of Inside the Operating Theater: Early Surgery as Spectacle, “by 1917 old-fashioned operating theatres had become obsolete…surgeons began to realize that speed was the variable…causing disastrous results – that indeed slower, meticulous incisions proved more efficacious” (Barry 2014). These efforts to improve professionalism and patient safety altogether reduced the drama inherent to a surgeon’s work.

 2

See Frederick Treves, “Address in Surgery: The Surgeon in the Nineteenth Century”, The Lancet 156, vol. 2 (1900): 312-317.

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By the late 19th century, eradication of functional operating theatres would have been complete if not for strong historical preservation efforts. The most famous theatres that remain are the Ether Dome, located at the Massachusetts General Hospital in Boston, and the Old Operating Theatre in London. These two historical landmarks were once functional spaces where, as Dr. Treves describes, the surgeon would “step into the arena.” Thousands of operations, predating anaesthetics and antiseptics, were performed (Ether Dome, n.d.) Today, these amphitheatres remind us of the great advancements made in surgical research, training, and patient care, and the many unwavering similarities that exist between the surgical and theatric disciplines (The Old Operating Theatre & Herb Garret, n.d.) Understanding the operating room as once an operating theatre is essential because it gives meaning to surgical theatrics, a term used to describe the formative and procedural occurrences that have dramatic origins within modern operating rooms. Surgical theatrics stem from the term theatrics, which are governances and routinised acts founded in the art of performance. Examples of surgical theatrics include roles within the medical hierarchy, props to assist the medical team in choreographed procedure, the use of apprenticeship in surgical education, and the necessity of an audience to uphold the surgeon’s accountability. These associations produce the following questions: are theatrics inherent to surgical practice, and can theatrics be applied to other medical fields? The science of preventing disease and the practice of relieving human suffering (i.e. medicine) are endeavours that are fundamentally emotional and exciting (i.e. dramatic). But theatrics are amplified on the surgeon’s stage more intensely than in any other discipline as a result of extreme tragedy and triumph, caused by intentional and traumatic human intervention. High stakes, high risk, high stress, a procedural degree of uncertainty, disease unpredictability – these are just a few of the many factors that contribute to similarities between operating theatres of the past and operating rooms of the present. The interspace between surgery and theatre is best illustrated in Thomas Eakins’ masterpiece, The Agnew Clinic, a painting which portrays key aspects of surgical theatrics at the turn of the 19th century. The decision to analyse surgical theatrics through a painting (as opposed to a script, protocol, or other art form directly associated with surgery and theatre) is intentional. The Agnew Clinic is an exemplar in which Eakins provides a momentary depiction of the medical team-medical traineepatient dynamic in the operating space. Eakins also illustrates a scene based on reality, yet distorted from the truth, thereby revealing a more accurate depiction of what is real. It is an image of Dr. Agnew’s clinic

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frozen in time, open for interpretation. Yet unlike the written word as offered through a script or protocol, Eakins’ painting offers a visual to aid his viewers with the emotion (or lack thereof), purpose, and action associated with each figure. Furthermore, The Agnew Clinic adequately represents a larger collection of works created by well-known artists including Rembrandt, Hinkley, and Babb – all of whom share an interest in illustrating the occurrences and dynamics within an operating theatre.3 It is for these reasons that The Agnew Clinic is an exceptional platform by which to analyse the intersection between surgery and theatre.

Figure 14

In 1889, Thomas Eakins was commissioned to paint a portrait of Dr. Hayes Agnew, a famous Professor of Surgery from the University of Pennsylvania School of Medicine. This painting was a gift from the medical students, honouring Dr. Agnew’s instruction, leadership, and career achievements. In three months, Eakins completed his depiction of the famous Professor as a hero of American medicine, clothed in polished white scrubs and standing at a distance from the operation. An anonymous

 3

The Francis A. Countway Library of Medicine, “Art & Artifacts”. Thomas Eakins (1844-1916). The Agnew Clinic, 1889. Oil on canvas, 84 3/8 in x 118 1/8 in, John Morgan Building at the University of Pennsylvania, Philadelphia, Pennsylvania. 4



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female patient lies unconscious on the operating table as several younger medical practitioners, also dressed in white aprons, perform a mastectomy. Eakins contrasts these characters with a dark background, saturated with students seated in the amphitheatre – many of whom are either asleep or appear entirely uninterested in the patient (Werbel 2007). Each person depicted in Thomas Eakins’ painting of The Agnew Clinic has a definitive role that communicates responsibility and limitation, two underlining features embedded within the surgical hierarchy. These welldefined roles contribute to the formative structure and governances within the operating theatre and are therefore examples of surgical theatrics. Take, for instance, the surgeon. Despite Dr. Agnew’s apparent expertise, he remains entirely uninvolved in the patient’s care. His scalpel, a symbol of prestige and technical competence, is untarnished and serves no use in the operation. Yet Dr. Agnew’s presence is absolute – his role as instructor, evident. There is, however, ambiguity as to whether Dr. Agnew is lecturing his audience on the surgical proceedings or whether he is directing the trainees from afar. In either case, his words do not fall on deaf ears. Eakins suggests listening is as much a part of surgical training as seeing, a perception that is illustrated in the red ears of Dr. Agnew’s medical staff and students (Warbel 2007) Listening remains an essential component to both theatre and surgery, yet Eakins’ representation of the medical students cautions this laissezfaire learning approach and suggests that it is not sufficient (Fox 1957). For the medical students, their eye-to-incision focus and “fourth wall” separation indicate an apparent interest that lies not in the patient but rather in the body and the disease. This concept of a “fourth wall” is a typical performance convention by which an invisible, imagined wall separates the actors from the audience. In Eakins’ painting of The Agnew Clinic, the audience (i.e. medical students) can see through this invisible wall while the actors (i.e. the surgeon, medical trainees, nurse, and patient) cannot. The fourth wall separating white coats from black jackets implies that these trainees will remain oblivious to the patient’s perilous situation – perhaps an attestation to the type of care they will one day provide. Although lectures on anatomy and attendance at clinics were the primary means of surgical education for medical students in the late 19th century, no method of instruction was considered more valuable than that of apprenticeship: the art of hands-on training which transforms the student into a master of his trade (Hoffman 1986). Surgical education has long been defined by apprenticeship, with the goal of fostering professional growth and potential in a demanding setting. In Eakins’ painting, there are three physicians at the operating table who perform the

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mastectomy. These medical trainees include: Dr. Ellwood R. Kirby, the resident physician who administers ether by the open drop method; Dr. J. William White, the most senior surgeon trainee who excises the diseased breast; and Dr. Joseph Leidy, the third physician trainee who monitors the patient’s pulse, and sponges blood from her body (University of Pennsylvania Archives & Records Center). Although each character’s role does not overlap the responsibilities of his colleagues, all three invariably depend on each other in a choreographed procedure (Fox 1957). Just as actors must follow a script, so too must medical trainees follow strict guidelines and protocols throughout their performance. As part of the hands-on training, medical trainees utilise tools – retractors, scissors, and forceps – which serve as essential props during the operation. These props allow trainees an opportunity to demonstrate technical competence and dexterity, skills that are continuously evaluated by the attending surgeon and observed by medical student bystanders (Brown 2017). Individually, the performance of Drs. Kirby, White, and Leidy requires physical stamina, knowledge of the human body, and presence of mind. Collectively, however, they compete for Dr. Agnew’s admiration and high marks. This “performance-evaluation” environment, in which the surgeon-medical trainee dynamic exists, amplifies the concept of surgical theatrics because trainees, by definition, operate with comparatively minimal expertise and an increased burden of uncertainty. Yet, by allowing these trainees to perform, the patient’s life and the instructor’s reputation are jeopardised. Herein lies the conflict: if surgical education requires apprenticeship and hands-on-training, and must be taught to and (at some point) performed by those who are inexperienced, does this not unequivocally gamble with the patient’s life, safety, and quality of care? Eakins illustrates this conflict by painting Dr. William White with a blood-stained apron. For it is on this stage that the medical trainees serve as antagonists to the expertise of the protagonist, Dr. Agnew. Drs. Kirby, White, and Leidy are guided by their attending surgeon’s instruction and expectation while the patient’s life remains dependent on their performance as students. It is for this reason that I call the operating space the “surgeon’s stage” – the physical space where the trainee’s performance is evaluated at different stages in his learning, and as a place where mastery is acquired by action on the vulnerable patient who surrenders herself to surgical craftsmanship. As with any performance, roles are typically vitalised by actors: persons who have personality and are influenced by the society in which they live. In this male-dominated habitat, Eakins includes Nurse Mary

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Clymer, a female character who embodies the societal transitions around her. Nurse Clymer’s importance in the operation is made evident by her height, one that is almost equal to that of the heroic surgeon, Dr. Agnew (Fox 1957). She stands upright and rigid, gazing at the patient to relieve the otherwise lacking patient-centred care in the theatre. Her clothing, a black garment covered by a white apron, depicts her place in the surgical hierarchy as an intermediate between the medical students and the physician trainees at the operating table. Although she is not experienced in the art of surgery, her art is that of the compassionate caregiver: “we must always be dignified and grave, never forgetting that all we are trying to do is for the good of the patient” (Barbara Bates Center for the Study of Nursing, “Portrait of the Nurse as a Young Woman”). However, it is not the role of caregiver that makes Nurse Clymer an unforgettable character. Rather, it is more generally the importance of her female presence, which marks a point of professional entry for women into the theatre as essential participants of the medical team. Although actors play an essential role in any drama, these roles do not necessarily require persons to create action or entertainment. Instead, surgical performance requires unseen or “invisible” characters (proponents that cannot be observed by the audience), which regulate the patient’s outcome. In the operating scene, it is the patient’s disease (a most natural human disorder) that contributes to the drama inherent to this enterprise since, without illness and disease, surgery would cease to exist. In Eakins’ painting, the most obvious symbol of the patient’s femininity is cut away under the intense and curious gaze of the male audience that surrounds her. Her breasts – one healthy and exposed while the other, replaced with a gaping wound – no longer exist as paired. This disfigurement encapsulates the essence of surgery; a medical specialty that requires physical injury with the intent to alleviate pain and suffering. Despite the many characters portrayed in Eakins’ painting of The Agnew Clinic, it is the patient and the sight of her exposed wound that suddenly make this scene an emotional work. One cannot look upon the unconscious woman without feeling discomfort due to the irreversible deformity that has been inflicted upon her. Dr. Benjamin Brodie (1782– 1862), a famous English physiologist and surgeon, explained to an audience of surgeons this natural desire to express emotion in the wake of human suffering: You must ever recollect, Gentlemen, that those beings on whom you are destined to practice are endowed with a percipient, thinking mind, and that that mind will become in the highest degree irritable from a variety of causes such as long confinement, sleepless nights, painful days….But it

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may be asked here, Who can regulate the minds of others, if they are incapable of commanding their own? and I therefore address to you the expressive words of the poet…‘Man, know thyself.’ I do not hesitate to say that he who can look with indifference on the agonies of the fellow creature is not the person to practice surgery. The Lancet, 3:54 (9 October 1824): 23

Dr. Brodie encourages his audience of surgeons to reflect on their own humanness and the great responsibility associated with their practice, yet Eakins’ representation of the medical team is quite different. Each student and provider in The Agnew Clinic is portrayed with a notable degree of emotional detachment, immune to the expression that should be felt by those in possession of such great and terrible authority. This may largely be due to the comfort and trust in anaesthetics, which “effectively silenced the patient …transform[ing] the operating theatre from shambles to a chamber of sleep,” and provided a way for the medical team to “cope with the more revolting aspects of their art” (Brown 2017). As a result of this expert, refined, distant, and meritocratic practice, the surgeon’s work has often been associated with a type of butcher’s trade. In spite of the medical team’s emotional insensitivity in the wake of human suffering, Eakins’ painting of The Agnew Clinic ultimately depicts surgery as a dynamic, performative art form – one that includes intraoperative roles, an audience to witness its spectacle, and unseen characters that drive an inherently dramatic enterprise. Eakins’ painting also depicts the inquisitiveness of science by illustrating a scene where the medical team is unable to effectively cure the patient. Removing the diseased breast does not change the patient’s perilous outcome but rather, according to Dr. Agnew, offers “the patient temporary relief from worry” and was therefore justified (Werbel 2017). In analysing the theatrics inherent to a surgeon’s work, the operating theatre becomes exemplified as a place of both mystery and prestige.

Operating Room or Operating Theatre? Despite the popular attendance of surgical performances within the operating room, spectatorship dramatically decreased with the discovery of Germ Theory and the general acceptance that public surgeries contributed to patient post-operative infection (Tait 1887). As a result, operating theatres were remodelled to become the aseptic and exclusive spaces distinctive of operating rooms in the 21st century. If surgical theatrics are an inherent part of surgery, then what aspects of the operating theatre exist in operating rooms today? I address this by analysing a

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contemporary piece created by the American realist artist, Joel Babb (1947- ). In his painting of The First Successful Kidney Transplantation, Babb memorialises the work of Joseph E. Murry (a plastic surgeon and winner of the 1990 Nobel Prize in Medicine) who participated in the first successful kidney transplantation at the Peter Bent Brigham Hospital in 1954 (Alpert 2014). Similar to The Agnew Clinic, Babb’s work provides a momentary depiction of the medical team-medical trainee-patient dynamic on the surgeon’s stage. Each figure has a definitive role that contributes to the surgical theatrics in this scene and, once more, acts of listening and observation are depicted as colleagues anticipate news about the surgical proceedings. In the history of medicine, Murry’s successful performance of the first kidney transplantation was an outstanding achievement – one that was highly publicised. Babb’s painting of the operating room includes a row of empty chairs, suggesting that the surgeon’s audience expanded far beyond the operating chamber. Just as family members and friends wait to hear about the status of their loved one, reporters lined up outside the Peter Bent Brigham Hospital – the world eager to hear about the success or failure of Murry’s work. Again, each physician requires knowledge of the human body, presence of mind, and operative dexterity, but in this painting, the medical team appears more dependent on intense cooperation and their tools to perform this innovative procedure. We are reminded of the unseen character and burden of uncertainty with which these surgeons operate, both of which are portrayed by the dash of crimson blood that covers the patient. Once again, light shines on the surgeons as the potential heroes or executioners in this narrative.

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Figure 25

Spectatorship remains an essential part of the modern operating experience, but does surgery necessarily require an audience? As illustrated in Eakins’ painting, operating theatres included amphitheatres which allowed students and faculty to observe the surgical proceedings. Their attendance was not merely for educational purposes, but also held surgeons accountable to practise ethically and with the highest quality. In seeming contrast, Babb depicts the operating room as a place behind closed doors – a room of mystery and prestige visible only to a select few that are privy to enter this most unnatural of environments. Today, recording and posting procedures on the Internet have become routine, allowing anyone in the public domain to view a surgeon’s work. At surgical conferences, live case demonstrations are now used as a way to present cutting-edge technology, giving physicians the opportunity to watch their colleagues perform in real time (Eliyahu et al. 2012). These live case demonstrations differ from videos posted on Internet sites, such

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Joel Babb (1947- ). The First Successful Kidney Transplantation, 1996. Oil on canvas, 70 x 88 inches, Harvard Medical Library in the Francis A. Countway Library of Medicine.



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as YouTube, because they do not show performances of the past. Rather, case demonstrations of the surgeon’s work are broadcast in real time, in the present. As part of these demonstrations, it is the patient’s unpredictable procedural outcome (an unpredictability paralleling operations that occurred in the operating theatre) which makes the surgeon’s work inherently theatrical in these situations. Should the patient’s condition improve, the surgeon could advance the enterprise of which he is intrinsically part. However, should any mistake occur, live case demonstrations could have profound consequences, jeopardising the surgeon’s career and creating irreversible complications for the patient. Analysing surgical theatrics in the operating theatre introduces the importance of spectatorship in the modern operating room as a means to reduce medical error and uphold accountability. But this perspective has also led to the question of whether surgery requires an audience and, if so, for whom are medical professionals performing? In a recent analysis by Dr. J Toouli (an Australian surgeon and former Editor-in-Chief of the International Hepato-Pancreato-Biliary Association Journal), he writes about the unpredictability of modern case demonstrations and describes a situation when a senior surgeon made a mistake (Toouli 2016): A significant technical complication occurred during the procedure, but my colleague was able to retrieve the situation due to his skill and experience. However, the patient’s chance of a postoperative complication significantly increased, both short and long-term. My colleague was distressed at the end of the demonstration … Two days later he flew home, never to see the patient again…. -

What are the ethical responsibilities of the surgeon demonstrator to the patient? Have they been fulfilled to a standard that would be acceptable in the surgeon’s own environment? What is the educational value of such an event to the audience? Did anyone learn anything from seeing Professor ‘famous’ get into trouble and thankfully get out of trouble? Faced with the same situation at some future date would the audience even remember this scenario and perform likewise? If it is a technique that we aim to teach would not a wellconstructed video fulfill the teaching objectives? 6

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Toouli, J. 2006. “What is the Role of ‘Live Surgical Demonstrations’ at Conferences?” HPB, no. 8: 163-164.

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Indeed, surgery does require spectatorship as a means of education and accountability. Dr. Toouli’s questions further suggest that spectatorship is inherently a part of surgery as a method of moral enhancement and quality improvement. Notably, though, these questions of ethics and training arise through our dialectic lens of the surgical and theatric disciplines. These topics are just a few of many possibilities for investigation, unveiling the multitude of ways in which theatrics within the surgical profession provide insight to better instruct the next generation of providers and provide the highest degree of care. Additional exploration of “surgical theatrics” as a field of study could have profound implications regarding attitudes and behaviours towards medical error, understanding patient confidentiality, and exposing new methods of improved patient outcomes.

The Evolution of Spectacle The art of surgery has evolved with biomedical, technological, and pharmaceutical research, but these advancements have not altered the theatrics inherent to a surgeon’s work. As a fundamentally dramatic enterprise, surgical practice continues to display theatrical components which originated from operating theatres of the past. These components are inherent to surgery, even though the spectacle – that is, the visuals and site of production – continues to change. Examples of these surgical components include: 1) props (including handheld tools and robotic devices); 2) distinct roles (characteristic of the medical hierarchy’s heightened measures to improve patient safety); 3) apprenticeship (as a means of guided and incremental learning); and 4) audiences (within the operating room or virtually). Despite the many analogous features that link surgery with theatre, the historiography of surgical theatrics has remained largely untouched. However, it is important to explore these features, not because they bridge medicine and the humanities, but because understanding surgical theatrics has the potential to improve surgical training, performance, patient care, outcomes, and the surgeon-trainee and surgeon-patient dynamics. Analysis of surgical theatrics can also open up discourse to a range of ethical and philosophical topics including the surgeon’s moral authority over a vulnerable patient (that is, the ability to make decisions which are right and good) (Brown 2017). These conversations can further address how

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emotions – such as fear, compassion, and grief – interplay in the patient and provider experience within the operating room. The evolution of spectacle on the surgeon’s stage represents a change of the physical space in which operations occur, but the governances and entertainment associated with the surgical art have remained consistent over time. As depicted in both Eakins and Babb’s work, the surgeons are detached from the emotional nature of their practice in a crude response to the tragedy of their action. The medical trainees’ expressions as depicted in The Agnew Clinic are visible, but faded. Dr. Agnew’s brows furrow in contemplation as he describes the procedure. Similarly, in Babb’s illustration of The First Kidney Transplantation, the surgeon is hidden behind the surgical mask, cloaking any emotional communication from the viewer. This is an important observation because it suggests that surgeons are not merely actors but also innovators, playwrights of the surgical enterprise and the patient’s fate. The surgeon’s ability to carve through human flesh provides them not only with the responsibility to give the greatest performance, but also with the responsibility to understand human disease and transform the human condition. Although Babb’s illustration might seem to suggest otherwise, emotional expression does continue to appear in the modern operating room. As minimally invasive procedures become more frequent and anaesthetics become increasingly effective and localised, patients are no longer unconscious on the operating table. The emotion inherent to surgical theatrics has evolved to once again include the patient who, in many ways, can now respond to and participate in the operation. Within the OR, the surgeon operates as both provider and discoverer, anesthetised to the emotional component of his work due, in part, to the routinised acts he performs; inspiring creativity that might otherwise be hindered by emotional sensitivity. Perhaps then, it is this act – that the surgeon should innovate while also reflecting on his own humanness – which is the greatest and most unexpected drama of all.

References The Francis A. Countway Library of Medicine. “Art and Artifacts.” Accessed on February 18, 2018. https://www.countway.harvard.edu/chom/scope-collections. Alpert, Jessica. 2014. “The Art of Surgery: Painting the Operating Room on Canvas.” Accessed on February 18, 2018. http://www.wbur.org/commonhealth/2014/12/17/the-art-of-surgerypainting-the-operating-room-on-canvas.

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Barry, Rebecca Rego. 2015. “Inside the Operating Theater: Early Surgery as Spectacle.” Accessed February 18, 2018. https://daily.jstor.org/inside-the-operating-theatre-surgery-asspectacle/. Bosk, Charles. 1979. Forgive and Remember: Managing Medical Failure. Chicago: University of Chicago Press. Bourdieu, Pierre. 1977. Outline of a Theory of Practice. Cambridge, UK: Cambridge University Press. Brown, Michael. 2017. “Surgery and Emotion: The Era Before Anesthesia.” In The Palgrave Handbook of the History of Surgery. London: Palgrave Macmillan. Cassell, Joan. 1991. Expected Miracles: Surgeons at Work. Philadelphia: Temple University Press. Davis, Audrey. 1982. “The Development of Anesthesia: Techniques of Controlling Pain Transformed the Practice of Nineteenth-century Medicine, Particularly Surgery and Dentistry.” American Scientist, vol. 70, no. 5: 522-528. Eliyahu, Shira, Roguin, Ariel, Kerner, Arthur, Boulos, Monther, Lorber, Avraham, Halabi, Majdi, Suleiman, Mahmoud, Nikolsky, Eugenia, Rispler, Shmuel, and Reyar, Rafael. 2012. “Patient Safety and Outcomes from Live Case Demonstrations of Interventional Cardiology Procedures.” Journal of the American College of Cardiology vol. 5, no. 2 (February): 215-224. https://doi.org/10.1016/j.jcin.2011.09.023. Fox, Reneé Claire. 1957. “Training for Uncertainty.” In R. K. Merton, G. G. Reader, and P. L. Kendall (eds.), The Study-physician: Introductory Studies in the Sociology of Medical Education, 207-41. Cambridge, MA: Harvard University Press. Hoffman, Stephen. 1986. Under the Ether Dome: A Physician’s Apprenticeship at Massachusetts General Hospital. New York: Scribner. Holland, J. G. 1879. “The Society of American Artists.” Scribner’s Monthly, no. 18: 311-12. http://bit.ly/2EArdGz. Hunt, Andrew. 1996. “American Medicine: The Quest for Competence.” JAMA 275, no. 7 (February): 568-569. https:10.1001/jama.1996.03530310074043. .Morgeli, Christoph. 1999. The Surgeon’s Stage: A History of the Operating Room. Basil: Editiones Roche. Newton, Michael. 1986. “Moral Dilemmas in Surgical Training: Intent and the Case for Ethical Ambiguity.” Journal of Medical Ethics, no. 12: 207-209.

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“Old Operating Theatre Museum & Herb Garret” Accessed on February 18, 2018. https://www.atlasobscura.com/places/old-operating-theatre. Panda, S. C. 2016. “Medicine: Science or Art?” Mens Sana Monograph, vol. 4, no. 1: 127-139. https://doi10.4103/0973-1229.27610. Payne, Lynda. 2007. With Words and Knives: Learning Medical Dispassion in Early Modern England. London. Ashgate Publishing. Pernick, Martin. 1985. A Calculus of Suffering: Pain, Professionalism and Anaesthesia in Nineteenth-century America. New York: Columbia University Press. Penn Nursing School, Barbara Bates Center for the Study of the History of Nursing. “Portrait of the Nurse as a Young Woman.” Accessed on February 18, 2018. https://www.nursing.upenn.edu/history/archivescollections/mary-clymer-collection/eakins-and-clymer/. Polavarapu, Harsha, Kulaylat, Afif, Sun, Susie, and Hamed, Osama. 2013. “100 years of Surgical Education: The Past, Present, and Future.” American College of Surgeons: The Bulletin. http://bulletin.facs.org/2013/07/100-years-of-surgical-education/. Prentice, Rachel. 2007. “Drilling Surgeons: The Social Lessons of Embodied Surgical Learning.” Science, Technology and Human Values 32: 535. Schatzki, Stefan. 2003. “The First Kidney Transplantation.” American Journal of Roentgenology, vol. 181, no. 1 (July): 190. Schilich, Thomas. 2015. “‘The Days of Brilliancy are Past’: Skills, Styles, and the Changing Rules of Surgical Performance, ca. 1820-1920.” Medical History, vol. 59, no. 3 (July): 379-403. https:10.1017/mdh.2015.26. Stanley, Peter. 2003. “For Fear of Pain: British Surgery, 1790-1850.” Clio Med, vol. 70, no. 3: 362. Tait, Lawson. 1887. “An Address on the Development of Surgery and the Germ Theory.” The British Medical Journal, Vol. 2, No. 1386: 166170. Toouli, J. 2006. “What is the Role of ‘Live Surgical Demonstrations’ at Conferences?” HPB, no. 8: 163-164. “The Ether Dome.” Accessed on February 18, 2018. https://www.atlasobscura.com/places/ether-dome. The Lancet, 3: 54 (9 October 1824): 23. University of Pennsylvania Archives & Records Center. “Medical Class of 1889: Commissioning of Thomas Eakins to paint ‘The Agnew Clinic.’” Accessed February 18, 2018. http://www.archives.upenn.edu/histy/features/1800s/1889med/agnewcl inic.html.

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Wangensteen, Owen and S. D. Wangensteen. 1975. “The Surgical Amphitheatre, History of its Origins, Functions, and Fate.” Surgery, vol. 77, no. 3: 403-18. Werbel, Amy Beth. 2007. Thomas Eakins: Art Medicine, and Sexuality in Nineteenth-century Philadelphia. New Haven: Yale University Press.





CHAPTER FIVE SPA ARCHITECTURE IN SZCZAWNO-ZDRÓJ MARIA SKOMOROWSKA

Introduction The therapeutic role of spa towns developed from ancient times, through the Middle Ages to the modern leisure destinations. Spas, based on mineral springs, were places for healing pain and disease with mineral waters before industrial medication developed in the 19th century. Spas provide medical treatment by applying mineral and thermal water including drinking cures, bathing, irrigations, hydrotherapy and mud treatments. The towns are a testimony to the development of medicine. Szczawno-Zdrój is located in Lower Silesia (southwestern Poland) in the Central Sudetes. It lies at an altitude of approximately 410 metres above sea level in the foothills of the Cheámiec mountain in the valley of the Szczawnik brook. The spa town borders industrial Waábrzych City to the east and southeast. The climate of Szczawno is gentle and refreshing: it is termed the climate of valleys in the hills, as it results from its location. Szczawno is sheltered from the southeast by the Park Mountain and the White Stone hills, while large forest areas protect the spa from the winds blowing from Waábrzych. Szczawno-Zdrój is an attractively located city with rich vegetation cover; the forested slopes of the surrounding hills and the deeply indented valleys make the area look recreational. About 60% of the area is covered by green areas: forests, pastures and meadows, and orchards. In the spa, there are two parks maintained in the English style (Zdrojowy and Szwedzki – 26.5 hectares) with rich native and acclimated vegetation (about 180 species), among which many trees and shrubs are natural monuments (Falkiewicz and Starzewska 1975, 40-56). Balneotherapy – the therapeutic use of hot springs – has been prevalent in Europe from ancient times to the present day. Many of the towns have been known since Roman times, and some of them have ruins of baths and associated spa buildings. The most famous spas reached the height of their



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popularity during the 18th and 19th centuries, when a wide range of new medical and health treatments was developed, and when travel became much easier because of the railways. Baden-Baden, Bath, Budapest, Karlovy Vary, Spa and Vichy are only a few of the famous European spa towns at the beginning of 20th century. Silesian spa towns grew into fashionable centres until 1914, SzczawnoZdrój being one of the most popular Polish spa towns. In the past it was known as Bad Salzbrunn and was a significant spa and popular leisure destination with a great cultural life. Located in the Sudety mountains, which are famous for their climate, Szczawno-Zdrój is a health resort based on mineral waters. Its cultural landscape has evolved through time, from the small settlement with mineral springs to the established spa town for the upper class with many entertainment facilities. In the middle of the town, the famous Grand Hotel grows out of the spa greenery (ZieliĔski 1996, 47-50).

Spa Architecture in Szczawno-Zdrój Szczawno-Zdrój (formerly Salzbrunn, Obersalzbrunn, Bad Salzbrunn, SáoĔsk, and Solice Zdrój) has existed in historical sources since the beginning of the 13th century. It was a village whose inhabitants had struggled with agriculture and weaving over the centuries, so its rich mineral springs waited a long time to serve people and cure their ailments. Its water’s health properties were scientifically researched by the Court physician Caspar Schwenckfelt in Jelenia Góra and published in 1601 in his dissertation. However, this did not initiate the career of the Szczawno waters and, for a long time, only local residents used them. The first spa doctor, founder and organiser of the health resort in Szczawno was Dr. Samuel August Zemplin. The Hochbergs, the spa owners, entrusted Zemplin with the management of the village in 1815, which, thanks to their financial support, was to become a resort effectively competing with the renowned spas of Europe (WrzesiĔski 2006, 211). August Zemplin was a very ambitious man who eagerly flaunted his relevance as a trusted person of Hochberg – the later Prince von Pless was residing at the nearby KsiąĪ castle – and used all the known properties of Szczawno to contribute to his glorification. However, the beginnings of the spa were difficult: before its formal opening in 1813, the village had modest chambers in only ten peasant huts, and only the lodgings in the Demuth mill and the local school could be considered satisfactory. Alternative accommodation was also offered by the old Pappelschenke



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guesthouse. The spa town was far from aesthetically pleasing and functional (Czech 2018, 165). The process of spa treatment is connected with the entire area of the spa town and requires the existence of appropriate equipment, installations and facilities. The basic component of the spa is the mineral spring. The health resort also houses treatment and wellness facilities, accommodation and recreational facilities for patients, diagnostic and laboratory facilities, offices and facilities serving spas, recreational green areas, as well as facilities for sanitary, communal and environmental engineering. Depending on the conditions, the individual components are centralised multifunctionally or only fulfil one function. The specific task of balneotherapy, the need to reconcile the climatic and natural conditions as well as the healing elements with modern technologies that facilitate and improve the functioning of spas, makes the environmental investments complex and long-lasting. There are some generally accepted norms for the design of spas; for instance, the mineral pump room should be located as near as possible to the occurrence of mineral springs, if possible by providing gravitational transport of water to dredging points, i.e. without the use of pumping installations. Medical facilities are also located as close as possible to the spring. Mineral water sources usually occur along dislocation lines, as in the valleys, where unfavourable microclimatic conditions often prevail. Even if this aspect is not relevant during short stays on treatments, the living facilities should have optimal climatic conditions with easy access to treatment facilities. Also, open pedestrian halls should have favourable microclimatic conditions. Environmental engineering ensures appropriate hygienic and sanitary conditions, which have a major role in the design and proper functioning of spa towns – starting from a suitable installation project in the baths and designing buildings in a way that facilitates ventilation, to heating and wastewater management projects. Proper spa design will ensure the development of the village, which will not adversely affect or disfigure the environment, will make appropriate use of natural conditions, and its landscape values will contribute to the constant movement of tourists and patients. One should also take special care in designing areas surrounding the spa; the location of industrial plants in close proximity to health resorts may lead to water pollution, and the development of mining in the spa area may result in the drying up of the source. The detailed location of spa elements depends on the configuration of the area, local climate, existing terrain, communication systems, rivers and reservoirs, existing buildings, the possibility of a water supply and sewage disposal. An excessive density of buildings may cause climatic changes: temperature, winds, or increased air



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pollution. The optimal size of the spa is defined as 1000-1200 places. In the 1970s, it was noticed that excessive expansion, leading to the formation of several dozen city-spas, resulted in town-planning activities being forced out by city-building factors. Also at that time, it was predicted that patients who were tired of living in large cities would be looking for rest in health resorts far from urban planning and architecture, and therefore the size of residential buildings should be limited. Spa construction, moreover, should not have the characteristics of hospitality and should create positive associations. The treatment process takes place not only inside swimming pools or treatment rooms, but also outside. In addition to the healing and accommodation functions, individual facilities also have commodity functions; therefore, it is necessary to ensure adequate mobility between buildings and the distribution of pedestrian areas and road traffic, greenery and places to rest. At the same time, the spa project should be as flexible as possible to allow future changes to treatment and treatment programs (Madeyski 1975, 21-83). In the early years of his position as a spa doctor and manager of the developing resort, August Zemplin was aware of the shortage of appropriate guesthouses ready to receive guests for healing stays, as the spa had been transferring the advantages of renting out accommodation to local peasants and weavers who were prepared to receive spa visitors in their homes. This type of stay in Salzbrunn was accepted until the supply of solidly or comfortably equipped hotels met the flow of even very demanding guests. Worth noting is the history of the building, one of the first in Szczawno, built for patients coming to the spa. On a small hill near the present forest amphitheatre in Spa Park, there was an old Pappelschenke guesthouse, around which transport was generating dust and noise, and the promenades arranged for patients became at the same time the routes for carts carrying goods to the spa. In order to prevent this, Zemplin decided to buy Pappelschenke, which he then had demolished due to its poor condition. On the site of the village pub, from which there was a view of the valley of Szczawnik (Salzbach) and of Cheámiec (Hochwald), a new, spacious guesthouse was built and named Pappelhof. The upper floor was intended for patients, while a pharmacy was created on the ground floor. The outbuilding next to the house served as a room for donkeys and goats: their milk and milk products, given in appropriate proportions along with the waters, according to the knowledge of the period, were reported to have a medicinal effect on health as they strengthened the body. This building has not survived to modern times as it burned down in 1852 (Czech 2018, 167). In 1818, Zemplin built a guesthouse in a meadow in the southern part of the park, near today's



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entrance gate, which he assigned for spa guests and called Wiesenhaus. It was a two-storey masonry and timber house with a half-timbered construction, typical of 19th-century Silesian architecture (Piątek and Piątek 1966, 52-73). In the footsteps of the enterprising Dr. Zemplin, others decided to build houses, villas, and guesthouses for the convenience of guests of the more and more popular spa. Each of these buildings had its name depending on the fashion or preference of the owners. In the 1820s and 1830s, Szczawno was ready to accept even the crowned heads and provide them with a standard appropriate to their status. The Hotel Zur Krone, erected in 1818, was designed for spa patients and guests of Salzbrunn, later renamed the Prussian Crown (Preussische Krone). During its construction, a source of mineral water was found, serving bathers today under the name Dąbrówka. It used to be in the basement of the building, which is now a sanatorium called Korona Piastowska. The building was repeatedly rebuilt in the nineteenth century, and subsequent transformations enriched it with an extensive dining room, orangery, meeting room, billiard and dance room, which is why this hotel was one of the most expensive in Szczawno, a fact that was also influenced by its location near the spa facilities. The Prussian Crown was also commemorated in literary works by Gerhart Hauptmann, who spent his childhood and early adolescent years there. Dr. Zemplin was the initiator of the construction of the picturesque Anna Tower, whose solemn dedication took place on August 18, 1818, in the presence of numerous gathered patients. The name of the tower was created as a reminder of Anna Emilia von Hochberg, who personally agreed to give the tower its name. It was a favourite place for walks by guests coming to Szczawno. Also, the recreational complex located in the eastern part of Zdrojowy Park owes its creation to Zemplin, who mentions the intention to create such a facility in a publication of 1822. In late summer of the following year (1823), the above project began and the first buildings of the belvedere were created and made available to the public for the first time on the birthday of the Prussian King Frederick William III. It was also commonly referred to as the Wilhelm Hill complex extending over three decades. One of the landmarks belonging to this complex, which could be reached on foot or on a rented donkey, was a viewpoint modelled on the gate tower in Stendal, from which guests could have a panoramic view stretching back several tens of kilometres (Korzeniowski 1855, 1). In 1842, an elegant restaurant was built on the hill and furnishing works were supervised by August Zemplin. Interiors of the adjacent colonnade were decorated with late Gothic decorative elements brought from Wrocáaw. In this colonnade a sandstone dog was exposed, a rare



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example of animalistic renaissance sculptures. An important investment, sought after by patients, was the building of a roofed facility to serve patients with the necessary mineral water for drinking, also during bad weather. The construction of the walking hall, modelled on the colonnade in Wiesbaden, began on April 2, 1830, when the cornerstone was laid. On July 26 the building was graced with the presence of the Prussian Princess Elizabeth and her husband Fryderyk Wilhelm IV, who gave their gracious permission to name the hall Elisenhalle. The colonnade, the construction of which was completed in 1831, consisted of 37 Doric columns and two portals. In 1836, the hall was extended and connected to a pump room. The previous pavilion over the Oberbrunnen (water intake, today Mieszko's source) was moved to Friedrichsruh, where it served the bathers as an arbour. The new pump room in the classical style, along with the colonnade, gave the opportunity to drink mineral water and walk without having to leave the building. In the hall, along the 83-metre-long western wall, there was a bazaar with 23 stores where guests could buy glassware, porcelain, magazines, and haberdashery. Guests could also use the services of a shoemaker, a glass cutter, an engraver, a turner or a tailor; in the commercial and service area there was also a library and a confectioner's shop. The service providers employed in the peak season of the resort were mostly recruited from the local population. The promenade and Elisenhalle, often referred to as a gallery, also provided, in addition to the above-mentioned benefits, the possibility of socializing (Czech 2018, 178). The main portal of Elisenhalle was about 45 feet wide and supported by six columns. On the left, there is a pump room 30 feet high, 28 feet long and 36 feet wide. On the right, there is a 292-foot walking hall, which, apart from varying the walk, also provided protection against rain and wind. The location of the hall was planned so that the column part would open from the south-east onto the promenade and the park. On the western, built-up side of the walking hall, along today's Kosciuszki Street, the brown waters of the Salzbach stream were heard (Szczawnik) and from the eastern side of the colonnade, one could observe the Máynówka flowing along the park promenade. Interesting aspects are the woodcarving of the first half of the nineteenth century and the map of 1838 that shows the course of the Szczawnik stream, whose entire length was discovered in the first decade of the twentieth century. In Zemplin's time, to increase the comfort of spa guests, spa houses (other names: social house, guesthouse, Kurhaus) were designed. Spa patients expected to be able to fill their free time in a way that provided entertainment, joy and respite during a long stay "at the waters". Such buildings were promoted to the name of cultural centres and combined several functions – there was a



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place for social gatherings, a common dining room, a place for lectures, concerts and, often, a hotel. The first spa house was built in SzczawnoZdrój in 1819. It was located next to the pump room, built in 1839-1842. The design of the pump room, stylistically referring to the old walking hall, is attributed to Josef Raaba, whose merits for Salzbrunn can be read in Gerhart Hauptmann's novel The Adventure of My Youth. The purposeful act of architects of the resort was to include the Kursalon (entertainment building) and Kurhaus (hotel and treatment building) in one building alignment of spa facilities with a walking hall, a pump room and a Spa Theatre (BaliĔska 1991, 110-140). The architectural idea used in Szczawno-Zdrój was part of the solutions commonly used to organise the space of resorts throughout Europe. The concept assumed not only the functionality of individual buildings but also the aesthetics and harmony of the image of the entire spa. The increasing number of guests forced further investments. In 1822, so-called tea evenings were organised, then dance parties – during the first reunion, according to Zemplin's recommendations, patients could only be listeners and spectators so as not to strain their weakened strength. Patients were also entertained by spa music: in the first years of the resort, only one musician performed, but in later periods spa guests were accompanied by a regular spa orchestra or a visiting mining orchestra from nearby Waábrzych. Instrumentalists also had an additional task, because until 1864 there was a habit in Salzbrunn of playing welcome music to every new guest who came to the waters (Czech 2018, 180). Also, at the initiative of August Zemplin, in 1821, the first theatre in Salzbrunn was built in the Deutsches Haus (German House), although it stood out of the way and the repertoire was not the best, in the opinion of local periodicals. In addition, the owner of the building did not receive money for renting the room for several years, so he allocated the whole building for housing. In 1836, the spa owner built a new theatre in a better location, a wooden building with a classicist top and external stairs. The theatre's interior, decorated with paintings by Wrocáaw painter Arrigoni, could accommodate 350 people with comfortable seating and a good view of the entire stage. In addition to the ground floor, the theatre had two galleries, the lower of which was divided into boxes. Both the galleries and ceiling were covered with painted decoration. This building has not survived to modern times. In 1890, the new theatre was built with a Baroque-Rococo interior, existing to this day. At the beginning of the 20th century, the spa base of the resort was modernised and extended. In 1901, the new bathroom building Luisa was put into use. Baths and balneological treatments were offered: there were



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44 bathing cabins, hydrotherapy rooms, showers, a sauna, an inhalation room, rooms for radiation and mud covering, as well as gymnasiums. A mechanical and chemical laundry was built nearby, as well as a pneumatic cabinet for treatment of airways. On June 1, 1910, the Grand Hotel – the present Spa House – was opened. The hotel, which now houses the Spa House, was erected at the beginning of the 20th century by the Kramer construction workers from Waábrzych, who worked for the Hochbergs. In documents and drawings can be found an architect’s signature: Eisermann from Berlin. The building refers to the classical style and has neo-Baroque elements. The façade of the three-storey building, covered with mansard roofs with two bells, is 104 metres high. The Hochbergs employed a hotel manager who had previously worked in hotels in London and Paris. A French-style garden was set up next to the hotel. The end result was stunning and the hotel shortly became a model for other spa hotels. One example is the Grand Hotel in Sopot. The Grand Hotel in Szczawno has received many famous people – including the German Emperor Wilhelm II, the King of Greece George I, and Ferdinand hr. von Zeppelin. In 1931, for financial reasons the health resort, along with the Grand Hotel, was sold to the German Earth and Construction Association. In 1934, the hotel was taken over by the Ministry of the Treasury and thus became a state building. The pump room, hotels, walking hall and all spa buildings in Szczawno are unique in Europe, and kept their original form despite the war and multiple fires. At the beginning of the 20th century, 42 new water intakes were made and grouped, depending on chemical composition, in eight teams. Five separate reservoirs of bathing waters were built, accumulating individual waters as a reserve for a period of increased demand. A sewage installation was constructed for the whole village. Flush lavatories were installed in all the boarding houses, hotels and residential houses. During World War I, there was a military hospital at the spa for wounded and sick soldiers, and hospital patients were also treated with drinking cures. Slowly, there was a change in the current treatment profile, set, among others, for the treatment of tuberculosis. It was found because of the effectiveness of Dąbrówka water in the treatment of diseases of the urinary system, as well as diabetes, liver diseases, bile ducts, obesity, and urinary gland disease. Mieszko water began to be used primarily in the treatment of catarrh of the upper and lower respiratory tracts, bronchial asthma, emphysema with catarrhal complications, and gastrointestinal disorders. Mieszko water proved to be effective in the treatment of hyperacidity. In 1931, the spa was sold to a Berlin construction company and in 1934 it became the national property of Germany. Another extension began in



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1938, when the bathrooms were rebuilt and enlarged. In 1939, a modern physiotherapy facility was put into operation, which allowed for medical treatments throughout the year, rather than just the summer months. The outbreak of World War II stopped the development of the spa. A military hospital and sanatorium were established in Salzbrunn and there was a small Bad Salzbrunn concentration camp in the town from 1944, which was a branch of the Gross-Rosen concentration camp. The fate of prisoners staying in this camp is unknown. They probably worked on the construction of the Riese building complexes. On May 8, 1945, the health resort was occupied without a fight by a unit of the 21st Soviet Army (Piątek and Piątek 1966, 78-99). On May 27, 1945, under the command of the First Front of the Ukrainian Soviet Army, power in these areas was delegated to the plenipotentiaries of the government of the Republic. On August 30, 1945, the Health Resort was transferred to the Polish authorities. Despite the activities of the spa in the period 1950-1989, its role consisted mainly in servicing preventive holidays. After 1989, as a result of structural and political changes in Poland, the organisation of preventive and therapeutic holidays gradually weakened, eventually disappearing altogether (àuczyĔski 2015, 89-92). At the beginning of the 1990s, and especially in the years 1994-1996, state expenditure on the functioning of the spa was noticeably lower. The number of places contracted for patients treated in sanatoria also decreased. It was necessary to make changes, which consisted in adapting the functioning of the spa to new economic realities. Beginning in 1996, changes were aimed at increasing the number of patients to be served by one hospital and sanatorial ward, from the current 40-60 to no less than 80. Rooms created as a result of these changes, after the necessary modernization and adaptation works, were allocated to potential patients. The next step was intensified actions aimed at improving the health resort’s infrastructure like, among others, the reconstruction of the Walking Hall and roof replacement in the Spa House. Further works also included adapting access roads to the spa, as well as driveways and entrances to the spa facilities themselves, which were carried out in order to adapt the spa facilities for people with disabilities. A major undertaking was works aimed at replacing historic, pre-war and uneconomic coal-fired boilers with gas or gas and oil ones. Further organizational changes in the functioning of the spa were related to planned modifications of the functioning of the health care system after the 1999 reform came into effect. At the same time, intensified work was undertaken to recruit private patients ready to pay for treatment in the spa with their own funds. At the end of the 1990s, the health resort treatment



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situation was very difficult: along with the privatization of spas, new problems arose which had never been seen before. In general, there was a gradual but lasting increase in tax payments, while the inflow of medical services was reduced. This situation was a serious threat to the further functioning of Polish spas, including Szczawno-Zdrój. At the beginning of the 21st century, the situation slowly began to improve. Strategy development of Szczawno during this period consisted in the continuation of activities undertaken in previous years. Emphasis has been placed on the development of treatment services. Currently, the spa operates in conditions of growing competition and constantly changing preferences and customer preferences. The adopted strategy brings measurable benefits. The health resort in Szczawno-Zdrój is a recognizable brand on the Polish spa services market with an innovative therapeutic and tourist offer. The spa operates in the field of spa medicine, rehabilitation, prevention of outpatient care, diagnostics and health, and tourism, offering 750 places for patients (Piotrzkowska and Mroczko 2018, 203). The sanatoria are located around the Mineral Water Pump Room and the Natural Medicine Institute. The most important, best-known and most prestigious sanatorium of Szczawno is the Spa House, the former Grand Hotel. The sanatorium has 300 places and offers lecture halls, three dining rooms, rehabilitation rooms, treatment and medical rooms, a spirometry studio, and functional heart examinations. The spa also offers a fitness club, cafe, the Máyn Culture Centre, and terraces and a large garden in summer. In SzczawnoZdrój, diseases of the musculoskeletal system and the respiratory system are treated, but the spa also treats patients with diseases of the digestive system, urinary tract, nervous system, and also those associated with defective metabolism. The spa development program includes: activities promoting the spa potential of Lower Silesia outside the country, investment and modernization of infrastructure (increasing the attractiveness of the town through the development of squares, care for cleanliness, order and aesthetics of buildings, and development of gastronomic and tourismrelated facilities), improving the qualifications and quality of tourist and medical staff, as well as training in the field of wellness and spas. Another very important and significant impact on the attractiveness of the place complementing spa services is the numerous tourist and recreational attractions of the spa and surrounding areas. Walking and sightseeing are appealing thanks to the climate and great nature.



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References BaliĔska, GraĪyna. 1991. "Uzdrowiska dolnoĞląskie. Problemy rozwoju i ochrony wartoĞci kulturowych do II wojny Ğwiatowej. Wrocáaw: Wydawnictwo Politechniki Wrocáawskiej. Czech, Iwona. 2018. „Samuel August Zemplin – twórca uzdrowiska w Szczawnie-Zdroju, Uzdrowiska Dolnego ĝląska”. InWizerunekMarketing- Media, edited by Mariola Szybalska-Taraszkiewicz, Marian Ursel, and Aleksander WoĨny (eds.), Wizerunek-MarketingMedia, 161-190. Jelenia Góra: Karkonoska PaĔstwowa Szkoáa WyĪsza w Jeleniej Górze. Falkiewicz, Antoni, and Maria Starzewska. 1975. Uzdrowiska dolnoĞląskie i ich okolice. Balneologia- historia-przyroda-sztuka. Wrocáaw: Zakáad Narodowy imienia OssoliĔskich. àuczyĔski, Romuald M. 2015. Uzdrowiska sudeckie w latach 1945-1950. Wrocáaw: Eko-Graf. Korzeniowski. Józef. 1855. „Spotkanie w Salzbrunn.” Gazeta Warszawska, 93(246): 1. Madeyski, Andrzej. 1979. Podstawy inĪynierii uzdrowiskowej. Warszawa: Arkady. Piątek, Eufrozyna, and Andy Zygmunt Piątek. 1966. Szczawno-Zdrój. Historia miasta i uzdrowiska. Szczawno-Zdrój: Zarząd Miasta Szczawna Zdroju. Piotrzkowska, Dorota and Franciszek Mroczko. 2018. „Historia i rozwój dziaáalnoĞci leczniczej w uzdrowisku Szczawno-Zdrój”. In Mariola Szybalska-Taraszkiewicz, Marian Ursel, and Aleksander WoĨny (eds.), Wizerunek-Marketing-Media, 191-210. Jelenia Góra: Karkonoska PaĔstwowa Szkoáa WyĪsza w Jeleniej Górze. WrzesiĔski, Wojciech. 2006. Dolny ĝląsk. Monografia historyczna. Wrocáaw: Wydawnictwo Uniwersytetu Wrocáawskiego. ZieliĔski, Andrzej. 1966. Uzdrowiska dolnoĞląskie na dawnej rycinie. Wrocáaw: Zakáad Narodowy imienia OssoliĔskich.



CHAPTER SIX THE GARDEN AS A TWENTY-FIRST CENTURY PANACEA? TRENDS IN SHAPING GARDENS AT HOSPITALS. A CASE STUDY OF COMPLEXES IN ENGLAND AND POLAND DARIA SàONINA

Introduction In the contemporary urban fabric, we increasingly have the problem of seeking harmony between the natural and artificial environments. This battle in the 21st century is extremely timely. Fortunately, one can notice the increasingly loud voices of nature which is slowly reviving in our cities. One type of green area that becomes a particular object of attention is the hospital garden. Their significance over the next years will increase, mainly due to the saturation of the urban fabric with buildings and the lack of free access to green areas, but also by searching for natural agents supporting the treatment process. Numerous studies prove that the garden or close contact with nature is an important element in the fight against disease. Interest in the healing influence of nature is becoming more and more popular. Today, one can notice the growing trend of "return[ing] to nature", manifested not only in technical fields, but also in medicine, which more and more often puts the patient in contact with fresh air. However, this is not a new thing. Since ancient times, there has been a strong relationship between man and nature. This relationship over the centuries has had its ups and downs. Today, the garden is no longer just an ornament; it is an integral part of therapeutic facilities, where its therapeutic properties are noticed. The space shaped as a therapeutic garden additionally supports the fight against disease. As many studies and

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examples of garden complexes show, this fight can be carried out in a friendly environment – a garden. Therefore, it seems necessary to promote the creation of gardens in various forms at therapeutic facilities.

Background: Gardens and their Healing Aspects A brief history of hospital gardens In the world of plants and animals, ancient peoples saw deities, sacred places of worship, and personal reflection and rest. In ancient Mesopotamia, one can find information on the use of plants with therapeutic effects and their conscious cultivation. In Egypt also, similar importance was attributed to, among others, anise, coriander, mint and sesame. The healing power of nature can be seen especially in ancient Greece, where places providing medical help were established near sacred places – i.e. streams, springs or rock formations. The conviction about the therapeutic properties of contact with nature developed especially in the Middle Ages. Hortus medicus combined compositions of herbaceous, spicy and ornamental plants with medicinal plants, which were used in the kitchen and created a specific character and landscape. Healing gardens established at hospitals became not only a valuable source of botanical knowledge or plant material, necessary for the production of preparations, but also a place of contemplation for the clergy. The spatial aspect is also visible in Persian gardens, where components of the garden interior gave positive energy and affected the internal feelings of the recipient. Until the 18th century, new proposals for reforming hospitals appeared in such a way that they would become institutions exclusively treating patients. The conviction was growing that supporting the sick was not only the Christian duty of monks, but also the duty of the whole community. The landscape of the hospital garden was then given more meaning, fitting into the whole spatial management. Contact with nature became an important aspect in the 19th century. It was noticed then that fresh air and sunlight were necessary for improving the sanitary conditions of the inhabitants of that time. Also, the link between the open urban space surrounded by vegetation and the physical and mental health of the inhabitants was also discovered (Gharipour and Zimring 2005, 497). This relationship was described in detail by Florence Nightingale, who for the first time described the healing activities of nature in the book Notes on Nursing in 1860. She believed that the visual relationship between man and nature, like the view from the window and

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flowers by the bed, supports the regeneration and recovery of patients (Gesler et al. 2004, 120-121). The 20th century brought about the loss of this belief. Developments in the field of medicine and pharmacology led to the treatment of green areas as representative forms, constituting only the decoration of newly created medical facilities. In many medical facilities, the creation of gardens was abandoned, in favour of parking lots, focusing on greater profit and productivity (Marcus 2007, 1-2). Interest in the influence of nature and the plants themselves on humans, manifests at the end of the 20th century: there is a lot of research in the United States regarding the link between a rapid recovery of convalescing patients with the impact of nature (Neduþin, Krklješ, and Kurtoviü-Foliü 2010, 296; Anthopoulos and Georgi 2011, 640). The search for a non-pharmacological source of health began on a large scale, and that search continues today. Research carried out by, among others, Roger Urlich (1984), Olds (1985) and Harting (1991), clearly shows that there is extraordinary healing power in gardens. Studies have shown that only a view of greenery can significantly reduce stress in patients, and also help them to take fewer painkillers, resulting in a faster recovery (Urlich 1984, 420-421). Observations by Francis and Cooper Marcus (1991) showed that people under stress and with negative feelings usually look for contact with nature, go to the park or look for a landscape view (Whitehouse et al. 2001, 301-303). Research was also carried out in many medical facilities, including four hospital gardens in San Francisco (1994) (Shan 2014, 141-142). Data on the behaviour of patients and their personal feelings related to staying in a green space were collected. As a result, it was clearly stated that an important aspect that decides about the healing effect of nature is the climate of the garden that contrasts with the hospital environment. Nature is the element that is closest to and most familiar in everyday life, in contrast to the walls of a hospital complex which is clearly associated with disease (Marcus 2007, 2-4). Due to the growing popularity of the healing properties of nature, more and more gardens at hospitals and other medical facilities are now an important part of therapeutic complexes. The health condition is more and more often related to the broadly understood therapeutic environment, where the natural environment plays an important role. Gardens become properly developed healing complexes which are adapted to patients' needs (Anthopoulos and Georgi 2011, 640-641).

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Gardens as healing landscapes The healing environment was first identified by Wilbert Gesler (1992). In the study entitled “Healing Places”, he broadly defined the therapeutic environment as a separate space, designed and adapted to the needs of a specific group of recipients (Gharipour and Zimring 2005, 492-495). Such a place can be the site of both therapies and individual contact, as well as interaction with the environment. Gesler also gives four aspects of the treatment of the environment – built, symbolic, social and natural environments – which will be associated in particular with green areas, whereas in the context of medical facilities they can be described as hospital gardens (Gesler 2003, 6-12). The complexity of the components of a medical environment is based not only on physical areas, since the separation of its symbolic and social aspects shows the importance of the emotional, religious and cultural spheres attached to it (Curtis et. al. 2007, 591-593). Research by Allison Williams (2007) indicates that the distinctive aspects complement and interact with each other (Perriam 2015, 20-22). Therefore, when talking about nature, greenery or gardens, it should be remembered that they are part of a greater understanding of the therapeutic environment. In the context of medical facilities, the architectural, landscape and psychological aspects will be of greatest importance.

Benefits of hospital gardens The beneficial effect of contact with nature on human health has been supported by numerous studies. Since the 1970s, increased interest in the given issue has resulted in the current state of knowledge, which allows us to draw significant benefits from the relationship between humans and nature (Figure 1) (Pachana, Mcwha and Arathoon 2003, 4). The direct impact of plants on humans is manifested as a result of the special properties of the plants themselves. By producing phytoncides, they naturally protect against bacteria, protozoa and fungi. The impact of plants on the negative ionization of air and the increase in air humidity are only two of the key direct effects on humans (Kuo 2015, 2). Contact with nature contributes to the improvement of physical ability and efficiency: a study by Roger Urlich (1984) on a group of patients after surgery proved that the view from the hospital room to greenery compared to the view of the neighbouring building can improve health and speed up the treatment process (Pachana, Mcwha and Arathoon 2003, 5-6). Other observed physical benefits are the reduction of blood pressure and pulse. Active

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interaction with a garden enforces physical activity, which relaxes the muscles and improves the physical coordination of patients. The overall improvement in physical performance is also important (Yücel 2003, 381382). In studies conducted by Kaplan and Kaplan (1983), the image of the garden as a place affecting the emotional state of patients clearly appears. The hospital environment is perceived as unfriendly, mainly associated with illness and disaster. According to Wilson (1984), the natural environment is soothing because of the process of human evolution, when the natural environment was a big part of everyday life before the modern period (Whitehouse et al. 2001, 302). The Canter and Canter (1979) study assigns similar significance to the natural environment, stating that it is necessary to create spaces as close to the natural environment as possible, by combining a view, water and plant material (Curtis et al. 2007, 594). Even passive contact with nature, observations of changes in cycles occurring within it or learning from fauna present in the garden affect the well-being of patients (Grahn and Strigsdotter 2010, 264). Feeling safe, the level of anxiety and stress significantly decreases, which in turn is an important element affecting a faster recovery (Dunzali, Yilmaz and Eren 2017, 7342-7343). This feeling of relaxation allows more effective sleep, leading to a general sense of well-being (Kuo 2015, 2-3). Plants also affect the senses; the variety of their texture, colour, smell, and wind movement is ideal material for conducting horticultural therapy (Kavanagh 1995, 105-106). The garden is also a place that creates appropriate conditions for social integration. The opportunity to participate in horticultural therapy helps to make new friends and improve teamwork. Patients do not feel lonely; they feel the need to act and cooperate. Arranging garden space into more or less intimate spaces allows patients to meet family or friends, but also enhances talking between patients and staff in less stressful conditions (Yücel 2003, 382-384).

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Figure 1. Benefits of hospital gardens and their mutual relations. Source: own study.

The hospital garden is an obvious element affecting the well-being of patients, but the benefits of contact with the green area also affect all hospital staff. An appropriate approach to the entire treatment complex – both in terms of the design of the building but also of its surroundings – can affect the work mode, employee morale and their involvement (Curtis et al. 2007, 594-595). Views of plants, colours and shapes are soothing and calming, while resting in the garden can be much more effective than in a closed facility (Anthopoulos and Georgi 2011, 642). In addition to the significant role of the therapeutic presence of the garden in a therapeutic complex, there are also economic benefits. The faster recovery of patients results in lower public sector financial outlays. A shortened stay at the hospital, as well as a smaller dose of medication may result in lowering the cost of treatment. The proven benefits of establishing various forms of gardens near medical facilities clearly show their value. However, is this relationship sufficiently appreciated in contemporary 21st-century cities in Europe? Further considerations will try to illustrate the degree of this awareness more accurately in the example of care for the development of garden space at hospitals.

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Material and Methods In light of the current demand for non-pharmacological methods of treatment and the contemporary need for contact with nature, this chapter focuses on the special environment consisting of healing objects and the green areas accompanying them. The main purpose of this study is to identify the way gardens are being developed at hospitals in England and Poland, thus highlighting the developed art of gardening in England with the newly discovered landscape architecture in Poland. It was also important to develop guidelines for shaping gardens near medical facilities in accordance with the needs of their recipients. The work is a review of the literature referring to the issue of the natural environment as therapeutic. The focus was on an outline of its main aspects combining the impact of nature on patients, also discussing the important role of gardens integrated in the treatment facility. A key element of the study is the case study of garden complexes at hospitals in England and Poland. Four gardens have been selected in England and four gardens in Poland (Figure 2). The criterion in the selection of research objects is the location of the complex in the hospital and the essential aspect is the existence of elements in the garden that would make it a medicinal garden. The analysis of these complexes is based on photographic material, written sources and local visions for gardens in Poland.

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Figure 2. Map of the study area. Examples of hospital gardens in England: 1. Horatio’s Garden at Salisbury Hospital, 2. Horatio’s Garden at Stoke Mandeville Hospital, 3. Orchard Garden at Bournemouth Hospital, 4. The Morgan Stanley Garden at Great Ormond Street Hospital, and Poland: 5. Garden at the St. Barbara Hospital in Sosnowiec, 6. Garden at the Oncology Center – M. Skáodowska-Curie Institute in Gliwice, 7. Therapeutic gardens at the Military Clinical Hospital with a Polyclinic in Wroclaw, and 8. Therapeutic gardens at the dr. Józef Babinski Specialist Hospital in Krakow (Kobierzyn). Source: own study.

Case Study Hospital Gardens in England The importance of gardens at hospitals in England was discussed in detail in January 2011; special value was given to gardens and it was recommended that hospital complexes should pay attention to shaping the green space. Are the postulates being implemented into the reality of modern medical complexes? Healing gardens in the UK are becoming more and more common. Thanks to established organizations such as Horatio's Garden, the close contact of patients with nature is greatly facilitated. The next section will focus on determining the form of exemplary garden complexes in the UK, also describing their impact on patients and each recipient.

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Horatio’s Garden at Salisbury Hospital Horatio’s Garden in the Duke of Cornwall Spinal Treatment Centre at Salisbury Hospital opened in 2012. It is the first complex created on the initiative of Horatio's Garden Foundation at the cost of approximately £300,000. The garden, named in honour of Horatio Chapple, the tragically deceased student of Eton, symbolises hope for a better future in which Chapple constantly believed. The garden designer was Cleve West, a landscape designer and winner of the Chelsea Flower Show in 2011, who experienced a friend’s long-term stay in the facility and created a perfectly suited space for the centre (Guinness 2012). The garden was shaped mainly to appeal to the senses in such a way as to create a spiritual sanctuary space for every visitor. The garden’s dimensions are 26 m x 34 m and it has a large area of hardened surface to adapt it to the specifics of patients' needs. Smooth paths made of gravel glued with resin are 2.5 m wide, making it possible to transport the patient's bed. The visible geometric composition of the surface in the form of dots in a bright shade makes the open square more attractive and it also contains the element commemorating Horatio Chapple. Elements identifying the space of the entire garden are three limestone walls leading to light arches. In addition to the function of street furniture, they have a symbolic meaning: the damaged and curved spine. The composition of the walls is complemented by rich vegetation, selected to affect the senses, so there are sensory rebates with species of fragrant and tasty herbs that stimulate the senses of smell and taste, or ornamental grasses that move with the wind affecting the sense of hearing. This sense is additionally stimulated by a water element – a stream located right next to the transitional pergola planted with Malus apple trees. The senses of touch and vision are provided with various textures of perennial plants such as Echinacea and Aruncus (Guinness 2012). In the garden, the designer also planned greenhouses with raised rebates, thanks to which patients can actively participate in the life of the garden by growing plants and caring for them. Horatio's garden is a place for both internal contemplation and group activities with horticultural therapy. Thanks to the separation of different areas, it is possible to meet with family or talk with staff, as well as to organise events. Thus, the garden has healing importance at many levels.

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Horatio’s Garden at Stoke Mandeville Hospital The third garden created by Horatio's Garden Foundation is the garden at Stoke Mandeville Hospital which opened in 2018. The medical centre at which the garden was established is one of the oldest and largest spinal injury centres in the world. When designing a garden for this significant centre, the designer had to demonstrate not only an understanding of the place but also the needs of patients. The designer was Joe Swift, a wellknown presenter of BBC Gardeners’ World (Horatio's Garden, n.d.). The main design idea was to create a haven, a place that brings patients closer to nature. The layout of the garden includes both more intimate and larger spaces for meetings of larger groups and the organization of events. Due to the specificity of the centre, the whole composition had to be adapted for free movement in a wheelchair or for people with limited mobility. Also in this case, the designer decided to work strongly on the senses of patients in the shape of a water element in the form of a cascade. Thanks to the rebate with perennial vegetation, the garden remains attractive for a long time. The planting of species attracting butterflies and birds that stimulate the senses of sight and hearing is also taken into account. The possibility of using the garden at any time of the year is ensured by a designed garden room, in which gastronomic functions were introduced for patients and their visitors. In addition, the greenhouse with raised rebates offers gardening therapy, so that patients can get to know each other better or take a break from hospital reality (Wharf 2006). The garden at Stoke Mandeville Hospital is of great importance to hospital patients. It has a healing effect mainly on patients' well-being and their social relations, thanks to a properly developed functional system and individual elements, affecting the senses or initiating integration (Horatio's Garden, n.d.). Orchard Garden at Bournemouth Hospital The garden at Bournemouth Hospital clearly shows the potential of areas near medical facilities, which until now were unattractive and unusable spaces. The design of the garden included transforming the courtyard into an attractive place with therapeutic value. The garden opened in 2017 and was dedicated to patients, their families and the hospital staff (Bournemouth Hospital Charity, n.d.). The layout of the complex is based mainly on a functional division which defines three zones. The first concerns the development of the courtyard between buildings with medicinal properties, where there are

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plant compositions of perennial and annual plants combined with street furniture, promoting time spent passively in nature. In addition, a form of interior decoration has been designed. From the courtyard there is a sensory path that leads to a wooden terrace by the lake, where apart from peaceful places of contemplation, the view has a soothing, healing effect. The designed platform allows access to the lake for people who cannot move around it freely. The whole composition has been designed to create a haven for patients, where they will have the opportunity to walk among plants or rest in the open air (Royal Bournemouth Hospital 2017). The Morgan Stanley Garden at Great Ormond Street Hospital The garden on the second floor of the Great Ormond Street Hospital is a remarkable example of successful cooperation between public sectors. The garden complex was created as part of an exhibition at the Chelsea Flower Show in 2015, after which it was placed in the target facility of the children's hospital in 2016. The designer, Chris Beardshaw, chose to create a place for reflection, which is extremely necessary for parents of small patients. The complex was shaped as an oasis of peace among lush vegetation, reminiscent of a forest environment. The colours of species of perennials stand out against the background of the surrounding buildings. The elements identifying this space are three pavilions inspired by Azumay's pavilions. One has an openwork canopy with a foliage motif – oak leaves. The designer composed the entire space with an artistic element – sculptures that perfectly fit into the plant and water composition (Great Ormond Street Hospital for Children 2016). The need to create similar spaces, especially in the highly saturated urban fabric of modern cities, is extremely important. In Great Ormond Street Hospital this space gives relief, aids relaxation, and gives hope to patients as well as their parents. The healing value of the garden consists mainly in providing a place of peace and rest, away from hospital rooms (Morgan Stanley 2015).

Hospital Gardens in Poland The areas around medical facilities in Poland still illustrate low commitment to their development. This is mainly caused by economic considerations, but also by insufficient awareness of the healing value of contact with nature. However, there are examples showing intervention in

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green spaces. The current form of development of revitalised gardens at selected hospitals in Poland is shown in the following section. Garden at the St. Barbara Hospital in Sosnowiec The garden at the Provincial Specialist Hospital in Sosnowiec was almost entirely commissioned in 2015. Work on revitalising nearly 28 thousand square metres lasted four years. The current form of development covers almost half of the green area of the hospital complex (PurzyĔski 2015). The purpose of the garden’s revitalization was to create a place to attract patients so they can recuperate faster by contact with nature. The current form of the garden is based on the earlier hospital layout, supplemented with rebates with an area of 12,000 square meters. The plants proposed had a floral composition, both perennial and shrubby, as well as dwarf bush varieties or bonsai-shaped ones. In the central part of the complex there is a water element that is backlit at night. Among the street furniture in the entire garden, benches, lanterns and waste bins have been replaced, and a playground has been designed, which is also used by nearby young residents (St. Barbara Hospital, n.d.). The garden encourages an active relationship with nature by patients and their families, as well as hospital staff. Despite the large area of the developed land, a large hospital complex prevents free access to the garden. The impact of the selection of plants on therapeutic effects is also questionable. However, the initiative itself and understanding the need to create such a space are adequate to the growing requirements of health care. Garden at the Oncology Centre – M. Skáodowska-Curie Institute in Gliwice The garden at the Oncology Centre in Gliwice is an example of the social initiative to transform and improve a green space into a lively garden. Garden recipients are mainly people with oncological diseases, for whom a strong sense of faith and hope is a very important element in the treatment process. The small garden space is located at the side of the hospital complex, bordering the road. The layout of the garden was dictated by the water reservoir in the form of a small pool with a wooden bridge connecting the two sides. The chosen plants are mainly aquatic species, planted near a water reservoir and smaller perennials and shrubs, in colourful varieties.

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The whole composition of the garden masks the view of the neighbouring street and encloses each of the visitors, creating large chamber-like spaces. The uniqueness of the garden lies in the initiative of collecting plants. All interested parties can provide plant material that will be planted in the garden. This creates, unfortunately, a random plant composition, which cannot always be supplemented with therapeutic properties. However, the existence of such a garden form is intended for visual interaction and to create a place of isolated contact with nature. Therapeutic gardens at the Military Clinical Hospital with a Polyclinic in Wroclaw The garden complex at the Military Clinical Hospital with a Polyclinic in Wroclaw consists of two gardens. The first is a small garden with a targeted therapeutic effect, intended for the therapy of people returning from foreign combat missions, suffering mainly from post-traumatic stress disorder (PTSD). The second is a larger park complex located at the back of the hospital building, which is a looser arrangement for passive, individual contemplation as well as for actively spending time (Augustyn 2008). In the therapeutic garden an area of 25 ares, a highly spaced evergreen hedge has been marked with a static form. In the composition of the garden there are stone elements referring to Japanese gardens: planting reveals more or less intimate spaces that encourage relaxation and observation of nature. The composition also masks the view of the surrounding buildings, thanks to which the feeling of consistency with nature is still strongly marked. A more active way of spending time is possible in the park garden, as patients can walk freely along the extensive pathways among the tree crowns (Trojanowska 2017, 208-209). Gardens, despite their differing forms, are designed to support the treatment of patients and facilitate their stay at the facility. The therapeutic garden offers the possibility of outdoor therapy in various forms, music therapy, art therapy and exercise. However, looking at the entire hospital complex, one can see an unused space that could be transformed into similar garden compositions. It is important, however, that the garden is actively used, which translates into the treatment process and the comfort of patients.

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Therapeutic gardens at the Dr. Józef Babinski Specialist Hospital in Krakow (Kobierzyn) The hospital complex in Krakow (Kobierzyn) was established at the beginning of the 20th century in an urban layout with reference to the garden city. The individual buildings were located with great respect and integration within the surrounding landscape. The centre is aimed at treating people with mental health issues (RoĪnowska 2017, 9-20). At present, in the hospital area, apart from the extensive park complex, several smaller spaces serve as individual branches of the therapeutic gardens, while a greenhouse can be distinguished as well. Horticultural classes are organised here, which have a strong impact on the social interaction between patients, making it easier for them to make friends and improve relationships. Plant care has an educational function in addition to therapeutic interaction. Thanks to the knowledge of basic principles, patients can look for employment in a similar field. Gardens are also a great tool for physical therapy and the resocialization of patients. The park, on the other hand, enables internal interaction with nature through walks among shady avenues. An important issue is the limited palette of vegetation colours, due to the specificity of the hospital (Trojanowska 2017, 2010-212). The hospital complex in Krakow (Kobierzyn) is an important example of combining history and the past with a modern approach to patient therapy, especially considering the needs of mentally ill people. Emerging gardens adapted for the needs of patients as well as various kinds of garden therapies not only support their quick recovery, but also shape their future independent life. Additional attention should be paid to the form of development of the newly created gardens, so they fit into the historic character of the entire complex.

Findings and Discussion On the basis of the analysed gardens at the hospitals, it is possible to combine their general features with the division of their components and the way they interact (Table 1).

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Table 1. General features of study area at hospitals Study areas

Poland

United Kingdom

Horatio’s Garden at Salisbury Hospital

Type of garden

Garden next to the building

Spatial elements Architectu Greenery ral Symbolic street furniture, water Sensory element, flowerbe d adapted surface, greenhous e

Way of usage

Type of impact

Plant growing, spending time, conducti ng therapy

Therapeutic impact, physical and mental benefits

Sensory flowerbe d

Plant growing, spending time, organisi ng events, conducti ng therapy

Therapeutic impact, psychologi cal and physical benefits, integrating Therapeutic impact, psychologi cal benefits, soothing, calming

Horatio’s Garden at Stoke Mandevill e Hospital

Garden next to the building

Water element, adapted surface, greenhous e, catering facility

Orchard Garden at Bournemo uth Hospital

Landscap ed courtyard and area near the pond

Decorativ e elements, sensory path, water element, platform

Perennial flowerbe d

Spendin g time, organisi ng events

The Morgan Stanley Garden at Great Ormond Street Hospital

Roof garden

Sculptural elements, water element

Forest corner, perennial flowerbe d

Spendin g time, rest

Therapeutic impact, psychologi cal benefits

Garden at the St. Barbara Hospital in Sosnowiec

Garden next to the building

Water element, playgroun d

Ornamen tal flowerbe ds, planting in the

Spendin g time, rest

Therapeutic impact, psychologi cal benefits

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style of Japanese gardens Garden at the Oncology Centre – M. Skáodowsk a-Curie Institute in Gliwice Therapeuti c gardens at the Military Clinical Hospital with a Polyclinic in Wroclaw Therapeuti c gardens at the Dr. Józef Babinski Specialist Hospital in Krakow Source: own study

An intimate garden next to the building

Water element, intimate seating

Ornamen tal flowerbe ds, large species diversity

Spendin g time, rest

Therapeutic impact, psychologi cal benefits

Park and garden at the entrance to the building

Entrance gate, green garden fence, rock formations

Park greenery, Japanese garden planting, perennial flowerbe ds

Spendin g time, rest, conducti ng therapy

Therapeutic impact, physical and mental benefits

Park and garden next to the building

Historical layout of pedestrian paths, greenhous e

Landscap e interiors, glade, perennial flowerbe ds

Spendin g time, rest, conducti ng therapy, educatio n

Therapeutic impact, psychologi cal, social and resocializat ion benefits

The list shows that the predominant type of garden is the area developed adjacent to the healing facility. In the case of the Morgan Stanley Garden at Great Ormond Street Hospital, the garden is located on the roof, which is extremely important when there is not enough space at the hospital for this type of arrangement: the roof garden form is increasingly used in the United States. The example of the Healing Garden at Smilow Cancer Hospital in New Haven shows how one can create a substitute for a real garden on the seventh floor of a building. The free arrangement of the garden, combined with sensory rebates and flowing water, gives a sense of closeness to nature, which patients mostly from less urbanised places need (Smilow Cancer Hospital 2010). In addition to the good accessibility of the garden, an additional advantage is

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the green view from windows, which also affects the general well-being of patients (Neduþin, Krklješ, and Kurtoviü-Foliü 2010, 296-297). Landscaping on a smaller scale can also bring significant benefits. The adaptation of the courtyard in the Orchard Garden at Bournemouth Hospital creates a more intimate character with more emphasis on decorative elements in the form of sculptures. An example of a similar use of courtyard space can be found in the Netherlands at Maasstad Hospital in Rotterdam. Despite the large proportion of built-up space and elements of landscaping, five internal gardens provide quick access to fresh air. At night, it is an unusual decorative element (World Landscape Architecture 2011). A more landscaped form of development of the hospital yard can be found at the Frimley Park Hospital in Hampshire, where planting creates an idyllic place, both for private meditation and larger group meetings (Pro Landscaper 2012). Another valuable form of garden near the medical facility is the open space, as in the case of gardens at the Military Clinical Hospital with a Polyclinic in Wroclaw and at the Dr. Józef Babinski Specialist Hospital in Krakow. Inclusion of a park in the functioning of a medical facility is important as a more active form of contact with nature. Examples of various forms of development of hospital gardens show that it is worth introducing a piece of green space even in small forms. Moreover, the combination of various types of gardens creates additional opportunities for spending time which thus impact on patients. Such a combination and wide variety of offered green space can be found at Fiona Stanley Hospital in Perth, Western Australia or at the Nelson Mandela Children's Hospital Garden in Parktown, Johannesburg, South Africa. Looking at the spatial elements in the hospital gardens analysed, water appears in each of them in various forms. The water element is desirable for auditory sensations, while affecting the sense of hearing with its soothing calm noise. It can also be an element reflecting the plant composition, the sky or light. In the aforementioned Nelson Mandela Children's Hospital Garden in Parktown, Johannesburg, South Africa water appears throughout the entire garden setting. The extraordinary nature of its occurrence is due to its form, appearing in various scenes. It can be seen in elevated water reservoirs with aquatic vegetation in the Quiet Garden, or as a stream cut into a surface homing towards the building, ending in a cascade (World Landscape Architecture 2017). Water also reflects life and passing away, so it has a symbolic meaning strongly affecting the human psyche. Another element that is present in each of the examples discussed is specific plant compositions. Depending on the possibilities, perennial flowerbeds, often exhibiting sensory properties –

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i.e. affecting the senses – are the intended purpose of the impact. In the case of the Morgan Stanley Garden at Great Ormond Street Hospital plants are an important element that give the whole garden a forest character, full of places fit for reflection. Similarly, the vegetation is shaped at Garden for Maggie's Cancer Caring Centre in Coatbridge, Scotland, where the healing properties of planting refer to a nearby forest environment. Thanks to the openwork form of the fence, the form of the garden creates an unusual composition with the nearby forest. In addition, plants introduced inside the garden affect a better union with the space, which in turn affects the internal experience (Landezine 2018). Interestingly, in most hospital gardens in Poland, the plant composition refers to the Japanese style which, in a sense, may be caused by the desire to refer to the general idea of the Japanese garden, whose composition was meant to soothe and calm. In one of the gardens analysed, a spatial form for young ones has appeared. In the garden at the St. Barbara Provincial Specialist Hospital in Sosnowiec, there is a playground in part of the complex. Its form corresponds to most of this type of setting in Poland. However, it is a very important place when it comes to providing contact with fresh air and nature for the youngest. At the Healing Garden at the Dell Children's Medical Center of Central Texas, USA, the entire garden composition has been subordinated to the needs of children. In addition to elements of street furniture that enable fun, there are also facilities designed to conduct outdoor therapy, such as music therapy. This is an example of garden development that shows how to create a perfect playground for children (Central Texas Gardener 2016). The main feature of each of the hospital gardens should be the therapeutic impact. The health aspect appears in all the examples analysed. In the examples of complexes in Great Britain, a form that enables patients to grow and cultivate plants appears more often, which is described as an additional element supporting the health of patients. In terms of the impact of nature on the treatment process, it is important to adjust the space to the needs of medical centre patients, as in the case of Horatio's Garden at Salisbury Hospital, where the garden’s shape, wide paths and smooth surfaces allow you to move in a wheelchair or even in a hospital bed (Guinness 2012). An example showing the close connection of land development around the hospital with the main purpose of the treatment centre is the previously mentioned Healing Garden at the Dell Children's Medical Center of Central Texas, USA for the treatment of children, as well as the Garden at Spaulding Rehabilitation Hospital in Charlestown, Massachusetts, USA. The garden can be described as a therapeutic pathway leading around the entire complex, its uniqueness lying in the

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precise planning of elements that improve the physical fitness of patients. Thus, one can find different slopes, walkways with ramps, different surface textures and distance markers. The whole has been colourfully decorated with vegetal cover, which additionally encourages the sense of touch and gives off fragrance, which in turn makes the rehabilitative walk more pleasant (Nilsen Morse 2014). It is important, therefore, that every space next to the healing facility affects both the physical and mental health of patients while also affecting social relations.

Conclusion Examples of gardens in the United Kingdom and Poland show many common features. The diversification of the stylistics and the spatial form is visible, which largely reflects the type of urban greenery in the countries concerned. In the context of the contemporary need for contact with nature, the creation of such complexes should be redefined. In addition to economic aspects, social education related to natural sciences is important. Thanks to this, it will be possible to undertake the creation of even better spaces in the future, not only at medical facilities, but also throughout the city. The current tendency to build a new therapeutic complex in relation to the external environment and to adapt the garden to the needs of patients is satisfactory. However, in countries where it is not possible to construct new facilities, it is also important to revitalise the existing area. In today's cities we are increasingly looking for additional green space. Gardens near hospitals could be an important part of the urban fabric, integrating the natural environment with the urban environment. The primary function of areas around medical facilities should therefore be to create a recreational form of setting. In addition, the introduction of medicinal elements could significantly affect the health of patients. The inclusion of such complexes in the urban fabric would also contribute to improving the health of its inhabitants, enabling social integration as well.

References Anthopoulos, Petros, and Georgi, Julia. 2011. “Landscape Preference Evaluation for Hospital Environmental Design.” Journal of Environmental Protection 2 (5): 639-647. doi: 10.4236/jep.2011.25073. Augustyn, Aneta. 2008. “They will Cure the Stress of Battle in the Therapeutic Garden.” Wyborcza Wrocáaw, August 29, 2008.

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http://wroclaw.wyborcza.pl/wroclaw/1,35771,5637996,Wylecza_stres_ bojowy_w_ogrodzie_terapeutycznym.html (In Polish). Bournemouth Hospital Charity. n.d. “Orchard Garden Project.” Bournemouth Hospital Charity. Accessed December 5, 2018. https://www.bhcharity.org/past-projects/orchard-garden/. Central Texas Gardener. 2016. “Orchids, Leeks and Healing Gardens at Dell Children's.” Central Texas Gardener. Last modified November 17, 2016. Accessed December 10, 2018. http://www.centraltexasgardener.org/2016/11/orchids-leeks-healinggardens-at-dell-childrens/. Cooper Marcus, Clare. 2007. “Healing Gardens in Hospitals.” Interdisciplinary Design and Research e-Journal 1(1): 1-26. Curtis, Sarah, Gesler, Wil, Fabian, Kathy, Francis, Susan, and Priebe, Stefan. 2007. “Therapeutic Landscapes in Hospital Design: A Qualitative Assessment by Staff and Service Users of the Design of a New Mental Health Inpatient Unit.” Environment and Planning C: Government and Policy 25(4): 591-610. doi: 10.1068/c1312r. Duzenli, Tugba, Yilmaz, Serap, and Eren, Emine. 2017. “A Study on Healing Effects of Hospital Gardens.” Fresenius Environmental Bulletin 26(12): 7342-7352. Gesler, Wil, Bell, Morag, Curtis, Sarah, Hubbard, Phil, and Francis, Susan. 2004. “Therapy by Design: Evaluating the UK Hospital Building Program.” Health & Place 10(2): 117-128. doi: 10.1016/S1353-8292(03)00052-2. Gesler, Wilbert. 2003. Healing Places, 6-12. 2003. Lanham: Rowman & Littlefield Publishers. Gharipour, Mohammad, and Zimring, Craig. 2005. “Design of Gardens in Healthcare Facilities.” WIT Transactions on Ecology and the Environment 85: 491-500. doi: 10.2495/EEH050501. Grahn, Patrick, and Strigsdotter, Ulrika. 2010. “The Relation between Perceived Sensory Dimensions of Urban Green Space and Stress Restoration.” Landscape and Urban Planning 94(3-4): 264-275. doi: 10.1016/j.landurbplan.2009.10.012. Great Ormond Street Hospital for Children. 2016. “The Morgan Stanley Garden for Great Ormond Street Hospital.” Last modified May 23, 2016. Accessed December 5, 2018. https://www.gosh.nhs.uk/news/latest-press-releases/morgan-stanleygarden-great-ormond-street-hospital-gosh. Guinness, Bunny. 2012. “Horatio's Garden: Horticulture for Healing.” The Telegraph. Last modified April 24, 2012. Accessed December 1, 2018.

The Garden as a Twenty-first Century Panacea? Trends in Shaping Gardens at Hospitals

103

https://www.telegraph.co.uk/gardening/9223347/Horatios-Gardenhorticulture-for-healing.html. Horatio's Garden. n.d. “Stoke Mandeville. Horatio's Garden.” Horatio's Garden. Accessed December 5, 2018. https://www.horatiosgarden.org.uk/the-gardens/horatios-garden-stokemandeville/. Kavanagh, Jean. 1995. “Therapeutic Landscapes: Gardens for Horticultural Therapy Coming of Age.” HortTechnology 5(2): 104107. Kuo, Ming. 2015. “How Might Contact with Nature Promote Human Health? Promising Mechanisms and a Possible Central Pathway.” Frontiers in Psychology 6 (August): 1-8. doi: 10.3389/fpsyg.2015.01093. Landezine. 2018. “Maggie's Centre by Rankinfraser Landscape Architecture.” Landezine. Last modified August 20, 2018. Accessed December 9, 2018. http://www.landezine.com/index.php/2018/08/maggies-centre-byrankinfraser-landscape-architecture/. Morgan Stanley. 2015. “Chris Beardshaw Designs the Morgan Stanley Garden for Great Ormond Street Hospital.” Last modified December 1, 2015. Accessed December 6, 2018. https://www.morganstanley.com/press-releases/chris-beardshawdesigns-the-morgan-stanley-garden-for-great-ormo. Neduþin, Dejana, Krklješ, Milena, and Kurtoviü-Foliü, Naÿa. 2010. “Hospital Outdoor Spaces: Therapeutic Benefits and Design Considerations.” Facta universitatis – series Architecture and Civil Engineering 8(3): 293-305. doi: 10.2298/FUACE1003293N. Nilsen Morse, Andrea. 2014. “Elements of a Therapeutic Garden – Exploring the Spaulding Rehabilitation Hospital Gardens.” Nilsen Landscape Design. Last modified August, 2014. Accessed December 10, 2018. http://www.nilsenlandscape.com/elements-of-a-therapeuticgarden-exploring-the-spaulding-rehabilitation-hospital-gardens/. Pachana, Nancy, Mcwha, Lindsay, and Arathoon, Maureen. 2003. “Passive Therapeutic Gardens: A Study on an Inpatient Geriatric Ward.” Journal of Gerontological Nursing 29(5): 4-9. doi: 10.3928/0098-9134-20030501-04. Perriam, Geraldine. 2015. “Sacred Spaces, Healing Places: Therapeutic Landscapes of Spiritual Significance.” Journal of Medical Humanities 36(1): 19-33. doi: 10.1007/s10912-014-9318-0. Pro Landscaper. 2012. “Frimley Park Hospital's 'Time Garden'.” Pro Landscaper. Last modified July 18, 2012. Accessed December 8, 2018.

104

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https://prolandscapermagazine.com/frimley-parkhospital%E2%80%99s-%E2%80%98time-garden%E2%80%99/. PurzyĔski, Piotr. 2015. “At the St. Barbary Arose Beautiful Gardens.” Wyborcza Sosnowiec. Last modified September 28, 2015. Accessed December 6, 2018. http://sosnowiec.wyborcza.pl/sosnowiec/5,93867,18924572.html (In Polish). Royal Bournemouth Hospital. 2017. “Outstanding’ Hospital Orchard Garden Wins Gold at South and South East in Bloom Awards.” Last modified September 23, 2017. Accessed December 5, 2018. http://www.rbch.nhs.uk/index.php?id=2442. RoĪnowska, Krystyna. 2017. “On the Periphery of Life.” In Krystyna RoĪnowska (ed.), Can go mad, 9-49. Kraków: Publisher WAM (In Polish). Shan, Jiang. 2014. “Therapeutic Landscapes and Healing Gardens: A Review of Chinese.” Frontiers of Architectural Research 3(2): 141153. doi: 10.1016/j.foar.2013.12.002. Smilow Cancer Hospital. 2010. “Healing Garden Provides a Place to Reflect.” Yale Cancer Center. Last modified June 23, 2010. Accessed December 8, 2018. https://www.yalecancercenter.org/news/article.aspx?id=646. St. Barbara Hospital. n.d. “Garden for Health.” St. Barbara Hospital in Sosnowiec. Accessed December 6, 2018. http://wss5.pl/pl/szpital/aktualnosci/1765-ogrod-na-zdrowie (In Polish). Trojanowska, Monika. 2017. Parks and Therapeutic Gardens, 208-212. Warszawa: Publisher PWN (In Polish). Urlich, Roger. 1984. “View through a Window May Influence Recovery from Surgery.” Science 224(4647): 420-421. doi: 10.1126/science.6143402. Wharf, Thames. 2006. “Horatio’s Garden – Stoke Mandeville – Design and Access Statement.” Last modified August, 2006. Accessed December 6, 2018. http://www.horatiosgarden.org.uk/wp-content/ uploads/2015/11/Horatios-Garden-Design-and-Access-StatementAugust-2016.pdf. Whitehouse, Sandra, Varni, James, Seid, Michael, Cooper-Marcus, Clare, Enserberg, Mary, Jacobs, Jenifer, and Mehlenbeck, Robyn. 2001. “Evaluating a Children's Hospital Garden Environment: Utilization and Consumer Satisfaction.” Journal of Environmental Psychology 21(3): 301-314. doi: 10.1006/jevp.2001.0224.

The Garden as a Twenty-first Century Panacea? Trends in Shaping Gardens at Hospitals

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World Landscape Architecture. 2011. “Orientation by Light, Maasstad Hospital, Rotterdam Netherlands Stijlgroep Landscape and Urban Design.” Last modified July 7, 2011. Accessed December, 2018. http://worldlandscapearchitect.com/orientation-light-maasstadhospital-rotterdam-netherlands-stijlgroep-landscape-urbandesign/#.XBt_klxKhPY. —. 2017. “The Landscape Spaces of Nelson Mandela Children's Hospital.” World Landscape Architecture. Last modified September 13, 2017. Accessed December 9, 2018. http://worldlandscapearchitect.com/thelandscape-spaces-of-nelson-mandela-childrenshospital/#.XBVs21xKhPZ. Yücel, Gökçen. 2003. “Hospital Outdoor Landscape Design.” In Murat Özyavuz (ed.), Advances in Landscape Architecture, Murat Özyavuz, 381-398. IntechOpen. doi: 10.5772/55766.

PART 3 EXPLORING MEDICAL HISTORY

CHAPTER SEVEN THE ONION (ALLIUM CEPA L.) IN LATE ANCIENT AND EARLY BYZANTINE MEDICAL LITERATURE (I-VII C. AD) KRZYSZTOF JAGUSIAKD E AND MACIEJ KOKOSZKO

The onion, or more precisely the bulb or common onion (Latin: Allium cepa L.) (on the identification of described species see André 1956, 80, 106 and André 1967, 56, 79) is a species classified, according to contemporary systematics, as a representative of the Alliaceae family. It probably derives from Central Asia. It appeared in the territory of the Middle East, Mesopotamia and Egypt very early – it was cultivated there already in the mid-3rd millennium BC. In the following centuries it spread further within the Mediterranean area, becoming one of the basic components of the human diet in the ancient world (Maáachowski 1977, 9, 12; Zohary and Hopf 1993, 185; Garnsey 2002, 81, 105; Dalby 2003, 240; Alcock 2006, 52-53; Brewster 2008, 1-5; Abdel-Maksoud and El-Amin 2011, 132, 140; Jagusiak 2014a, 203-204). The Greeks used to call it krómmyon or krómyon (Pape 1908, 1512; Liddell and Scott 1996, 998), whereas in Latin it was known under the name cepa or cepe (Korpanty 2001, 304; Plezia 2007, 407). However, for example, in 4th-century Palladius’ treatise entitled Opus agriculturae [3.23.1-9] this vegetable occurs under the name of cepulla, and a similar form written by only one “l” [cepula] also appears incidentally in the 4th/5th century De re coquinaria [9.2.1] (Cf. Nehring 1923, 4; this term was initially a diminutive). Its importance was not diminished in the times of the early

 D

 Waldemar Ceran Research Centre for the History and Culture of the Mediterranean Area and South-East Europe (Ceraneum), University of àódĨ, Poland. E  Department of Byzantine History, University of àódĨ, Poland.

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Byzantine Empire – the collapse of which constitutes the bottom line of our study – when it still remained a common vegetable found in the everyday simple diet of ordinary people, in the menu of Christian monks avoiding luxury, and among ingredients of haute cuisine (Koder 1993, 53, 88-90, 91-93; Talbot 2007, 119; Kokoszko and Jagusiak 2011, 47; Kokoszko 2011, 528; Anagnostakis 2013a, 101; Anagnostakis 2013b, 57; Koder 2013, 144). The preserved Greek and Latin sources demonstrate a great interest in the onion. We will discuss medical treatises in the following part of our chapter. At this point, however, we would like to mention information derived from other kinds of sources. As far as the period we are interested in is concerned, Allium cepa is mentioned in agronomical treatises written by Columella (1st cent. AD), Palladius (4th cent. AD) and the anonymous Geoponica which, though finally edited in the 10th century, includes extracts falling into the time framework set for this study. The onion was also mentioned in the work on culinary art entitled De re coquinaria (probably 4th cent. AD), and Deipnosofistae by Athenaeus of Naucratis (3rd cent. AD). Based on the study of this diversified group of texts (which are of an auxiliary nature for us) there emerges a complex picture of the vegetable which has many applications in everyday life. First of all, it must be emphasised that many varieties of the onion were known – they differed from one another in their size, colour, flavour, intensity of aroma, eye irritation when cutting the vegetable, or time of planting; its properties also changed depending on the region from which the vegetable originated (Pliny, HN 19.32.101-107. Cf. opinions of Theophrastus, who lived ca. 400 years before Pliny [HP 7.4.7-10]. Pliny’s account, though it is probably not comprehensive, offers many details, lists areas famous for onion cultivation – such as Sardinia, or Samotrake – and characterises some better known places of famous cultivars (for example, ascalonian and tusculan). The onion was commonly eaten and prepared in many different ways. Although the purpose of this study is not to discuss the culinary function of the described plant, it is worth mentioning that the sources from the period concerned preserved references on preparing various meals using onions, from simple ones to those more complex and containing multiple ingredients. A treasure of data describing the role of the onion in culinary art in late antiquity is a treatise entitled De re coquinaria – sometimes erroneously attributed to Apicius – in which information on, inter alia, soups, sauces, puree, complex dishes, and compound stews [like sala cattabia, patina, patella, minutal, conchicla], and also, for example, on some methods of its preparation, like drying, could be found. (Cf. De re coq., 3.4.7; 3.15.1-3; 4.1.2; 4.2.6; 4.2.18-19;

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4.2.30; 4.2.32; 4.3.6; 4.4.1; 5.3.4; 5.4.2; 5.4.4-5; 6.2.2; 7.6.3-4; 8.6.9-10) Some information concerning the consumption of onions could also be found in other works written in the period covered by this chapter, for example, in De re rustica of Columella [12.59, 1-2] from the 1st century AD. The author placed there a few recipes for salads with green onion as one of the ingredients. In turn, the anonymous author of Geoponika [12.31.6] from the 5th/10th century wrote about eating raw onion with honey. As for medical literature from the period we are interested in (since this is what we intend to focus on), some fragments on the onion – crucial for our study – may be found in the works of authors writing in Greek, namely: Dioscorides (1st cent.) (Wellmann 1905, 1125-1143; Riddle 1980, 1-143; Riddle 1985, passim; Denham and Whitelegg 2014, 191-209), Galen (2nd/3rd cent.) (Sarton 1954, passim; Bednarczyk 1995, passim; Debru 1997, passim; Nutton 1999, 359-370; Hankinson 2008, passim), Oribasius (4th cent.) (Schröder 1940, 797-812; Baldwin 1975, 85-97; López Pérez 2010, passim; Jagusiak and Kokoszko 2011, 5-21), Aetius of Amida (6th cent.) (Wellmann 1894, 703-704; Lehmann 1930, 205-206; Nutton 1984, 1-14; Scarborough 2013, 742-762), Alexander of Tralles (6th cent.) (Thorndike 1964, 1-47; Duffy 1984, 21-27; Garzya 2005, 27-28), and Paul of Aegina (7th cent.) (Rice 1980, 145-191; Salazar 1998, 170187; Pormann 2004, passim). Therefore, it is included in the writings of the most significant physicians whose works have remained until today, which itself proves the great role of the discussed vegetable in those times. It is worth supplementing the findings made by the aforementioned specialists with data obtained from Latin works whose authors had not completed a professional medical education, but nevertheless possessed vast theoretical knowledge (connected with knowledge of professional literature) which corresponds with the stage of medical development in those times. We hereby refer to such writings as De medicina written by Celsus (1st cent. BC to 1st cent. AD) (Crum 1932a, 153-159; Crum 1932b, 161-165; Fagan 2006, 190-207), Historia naturalis by Pliny the Elder (1st cent. AD) (Kroll 1951, 271-439; Nauert 1980, 297-422; Stannard 1982, 323; Healy 2000, passim) or Medicinae ex holeribus et pomis by Gargilius Martialis (3rd cent.) (Riddle 1984, 408-429; Bonet 1995, 139-157; Krynicka 2015, 182-198). Finally, it is worth referring to the treatise entitled De observatione ciborum written by Anthimus (6th cent.), which we mention at the end. Although, as opposed to other analysed Latin works, it was written by a man with a medical education, it is extremely concise and does not provide a lot of additional information.

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In his description of the dietary properties of the onion included in De materia medica, Dioscorides wrote that different varieties of the vegetable indicate a different pungency, similar to raw onions as compared to those processed, e.g. roasted or pickled – dried onions are sharper, while raw ones are less sharp. Baked, or salted [pickled] onions are milder, (cf. Diosc., Mat. med. 2.151.1.1–3). Onions irritate the human body and have a carminative effect, while they stimulate appetite (Diosc., Mat. med. 2.151.1.4–2.9). Dioscorides also classified them as attenuating products and added that they cause thirst, may cause nausea and have a cleansing effect (Diosc., Mat. med. 2.151.1.1–2.9). The author also said that onion has a good influence on the bowels, and helps in defecation. He also claimed that the said vegetable stimulates bleeding and may cause menstruation in women (Diosc., Mat. med. 2.151.1.1–2.9). Cooked onion also has diuretic properties (Diosc., Mat. med. 2.151.1.1–2.9). To some extent, it may be concluded that Dioscorides attributed heating properties to the described vegetable since he mentions that when someone wanted to get rid of bruises, they applied cheese soaked in brine on the skin. Nevertheless, in order to enhance the effect of such a compress, some onion juice could be added to it (Diosc., Simpl. med. 1.53.3.3–5). Moving on to the medical applications of the onion in Dioscorides’ work, first it is worth noticing in his works three main groups of ailments in which Allium cepa was to be helpful: dermatological, ophthalmological and otolaryngological. As far as the first group of disorders is concerned, Dioscorides claimed that in the case of alopecia areata (alopekias) the affected areas on the scalp or chin should be rubbed with onion juice (which is more effective than alcyonium) (Diosc., Mat. med. 2.151.2.6–7). As for the term “alcyonium” it probably meant a kind of sponge in some way connoted to halcyons (cf. Parr 1809, 67), or with onion pulp (Diosc., Simpl. med. 1.89.3.1). In the case of a white rash of alphós type appearing on the skin, onion should be mixed with vinegar and the obtained fluid should be applied to the skin; then the skin areas covered with it should be exposed to sunlight (Diosc., Mat. med. 2.151.2.1–2). If onion juice is mixed with an equal amount of ash (Dioscorides did not specify the origin of the ash), the obtained substance will bring relief when applied to itchy areas around the eyes (also if the eyelashes fall out), while it will also help to get rid of facial blemishes (Diosc., Mat. med. 2.151.2.2–3; Diosc., Simpl. med. 1.45.1.5). Finally, the so-called black alphós can be dealt with using onion juice and wine vinegar (Diosc., Simpl. med. 1.113.1.4). As for eye diseases, according to Dioscorides, Allium cepa juice mixed with honey should be applied in people complaining of vision impairment and various problems resembling cataract (Diosc., Mat. med. 2.151.1.7–9

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[onion juice]; Diosc., Simpl. med. 1.40.2.7 [onion]; 1.42.1.2–3 [onion juice]). In the case of the third group of diseases, the author of De materia medica believed that a mixture of onion juice and chicken fat – most probably applied as drops – helps in the case of various hearing problems (e.g. tinnitus) and in situations similar to otorrhoea that may sometimes feel like ears filled with water (Diosc., Mat. med. 2.151.2.3–6; Diosc., Simpl. med. 1.60.3.4; 1.61.1.3; 1.62.1.1–2). In the case of throat ulceration (at present referred to as tonsillitis), drinking or smearing the inner side of the throat with a mixture of onion juice and olive oil was helpful (Diosc., Simpl. med. 1.82.2.4; Diosc., Mat. med. 2.151.1.6–9). According to Dioscorides the onion has a number of applications, also in other ailments of a different nature. To give an example, a poultice with onion and hen’s fat, or álfita barley groats brings positive effects in the case of feet abrasions (Diosc., Simpl. med. 1.164.1.3), whereas a cataplasm of rue, salt, honey and onion juice is helpful in bites from animals (dogs) infected with rabies (Diosc., Mat. med. 2.151.1.9–2.1; Diosc., Simpl. med. 2.120.4.2). A description of dietary properties and medical applications of the onion was also left by Galen. In his treatise De alimentorum facultatibus he claimed that the vegetable’s roots are more delicate – just as in the case of garlic and leek – as compared to its stalks and leaves, which are very pungent, have heating properties, attenuate thick juices and thin those that are sticky (Gal., Alim. fac. 658.11–14, vol. 6). It is difficult to compare the elements of this division to modern, scientific descriptions of onion divided into the following parts: roots, reduced stem, leaves, bulb, style, and also, at the later stage, inflorescence (Cf. Chroboczek 1970, 31-41). In relation to the onion’s sharpness (cf. Gal., Vict. att. 75.3; Gal., Bon. maliq. 794.14–17), an onion cooked once or twice loses its bitterness, while it retains its thinning properties and provides not much nutrition for the body It does not nourish the human body at all until it is cooked (Gal., Alim. fac. 658.14–17, vol. 6). The description is supplemented by references scattered over Galen’s work; they suggest that the vegetable has intensive healing properties (Gal., Simpl. med. 48.13–14, vol. 12; Gal., Comp. med. 600.7, vol. 12; Gal., Vict. att. 22.3; Gal., Bon. maliq. 808.14). It is also – together with garlic, cress, leek and mustard – a powerful thinning product, being more effective in this respect when it is dry than when it is raw (Gal., Vict. att. 7.1–8.1. According to Galen, even foods from onion like sauces of hypotrimmata-type are thinning, cf. Gal., Vict. att. 21.1– 22.6). This last property makes it a suitable product to be eaten by the elderly preventing the blockage of bile ducts, enlargement of the spleen and formation of calculi in the urinary tract (Gal., Sanit. 340.15–341.4).

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Finally, particularly fresh, i.e. full of juice, onion is defined as a carminative product (Gal., Simpl. med. 48.13, vol. 12). As for medical applications of onion, Galen confirms to a large extent the findings of Dioscorides, also quoting Greek medical authorities such as Archigenes, Apollonius and Soranus. In his output we may find information corresponding to data provided earlier by the authors, but supplemented by additional, or completely new, findings as compared to the legacy of Dioscorides. Onion appears once again as a helpful product in specific dermatological problems. Rubbing it, mixed with vinegar, onto the scalp and exposure to the sun is a cure against alphoí (Gal., Simpl. med. 48.13, vol. 12). It should also be rubbed onto skin affected by alopecia areata since it stimulates hair growth (Gal., Simpl. med. 48.13, vol. 12), though it must be remembered that these areas should be massaged thoroughly first (Gal., Comp. med. 407.14–15, vol. 12). One may also, having punctured the affected skin area beforehand, rub in crushed onion mixed with honey (Gal., Comp. med. 408.2–4, vol. 12; 415.15–416.6, vol. 12). According to yet another method of treatment if this health problem persists for a longer time, one should shave one’s head, apply mustard plasters triggering skin redness, rub/massage the affected areas and then rub in tar or cedar oil or fig leaves, or, ultimately, onion (Gal., Comp. med. 415.6–11, vol. 12). A second group of ailments that in Galen’s opinion should be managed with Allium cepa includes problems of an otolaryngological nature. The 2nd century physician mentioned that, among peasants who tried to cure otalgia cases caused by hypothermia, he came across the following procedure: having hollowed out an onion, they poured some oil into it, put it into hot ash and then instilled the substance into their ears; others cooked onion and garlic in oil and then poured it into a patient’s ear (Gal., Comp. med. 600.9–15, vol. 12). The author of De compositione medicamentorum secundum locos does not entirely agree with that procedure and instead recommends instilling old oil with euphorbia or well ground pepper into the ears (Gal., Comp. med. 601.1–5, vol. 12). In the case of otitis Galen recommended applying a heated mixture on the ear consisting of twelve wingless cockroaches, mature wine, honey, pomegranate peelings and leek juice cooked together in a new ceramic pot until the pomegranate peelings soften. Next, the ingredients should be pulped and a substance described as Syrian oil was to be added together with liquid tar and the juice of four onions so that all those ingredients changed into a homogenous mass (Gal., Comp. med. 631.17–632.6, vol. 12). The mixture should be applied with wool. As for various ailments resulting in hearing impairment (deafness, tinnitus, hearing loss, etc.) Galen recommended treatment with

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eardrops as well as different types of rinses containing pulped onion or onion juice and other ingredients, e.g. honey, goose fat, pine resin or oil (Gal., Comp. med. 647.4–6, vol. 12; 648.2–3, vol. 12; 651.15–16, vol. 12; 658.17–18, vol. 12; 659.8–9, vol. 12). In his oeuvre Galen also presented a procedure which suggests onion application in the case of problems with vision. Onion juice, characterised by natural warmth, was to be rubbed in around the eyes in the case of cataract or visual impairment caused by the presence of thick juices in those areas (Gal., Simpl. med. 48.13, vol. 12). About 150 years after Galen, Oribasius presented a specification of the dietary properties of the onion. In a specific fragment of Collectiones medicae, he described the features of Allium cepa together with other vegetables classified as falling into the same group, such as garlic and leek. He confirmed that these vegetables are characterised by considerable pungency (Orib., Coll. med. 2.27.1.1). In a different passage he also added that they have heating properties (Orib., Syn. 2.6.1.1–3). He also wrote that all of these vegetables in this group warm the body and cut its thick and sticky juices (Orib., Coll. med. 2.27.1.1–2.1). After being cooked two or three times, the onion (and other representatives of this group) loses pungency; however, it retains its ability to thin thick substances (Orib., Coll. med. 2.27.2.1–3.1). Subject to thermal processing, it does not provide much nutrition to the body (Orib., Coll. med. 2.27.3.1–3). In other fragments of Collectiones medicae, Oribasius included further details on the onion which he described as a product with attenuating properties (Orib., Coll. med. 3.2.1.1) and as a vegetable containing bad juices (Orib., Coll. med. 3.16.14.2). In his Synopsis ad Eustathium filium Oribasius also wrote that the onion should be included in the group of products containing thick juices (Orib., Syn. 3.2.23.1–2). Another analysed author, Aetius of Amida, repeated some of the information provided by his scholarly predecessors, concluding that the onion is classified as a heating product (Aet., Iatr. 1.232.1). Mixed with vinegar, applied to skin and exposed to the sun’s rays, it helps in the case of skin lesions (blemishes) referred to as alphós (Aet., Iatr. 1.232.3). According to Aetius, onion is also a medication which should be rubbed onto skin to treat cases of alopecia areata, and it is more effective for this type of problem than alcyonium as it eliminates hair loss more quickly (Aet., Iatr. 1.232.4–5). Eating onion, after it has been thermally processed, leads to the cutting of thick and sticky juices in the consumer’s body (Aet., Iatr. 1.232.5–6). Onion may cause flatulence due to the density of its compositional substance (Aet., Iatr. 1.232.6–7). The next medical author, Alexander of Tralles, in a chapter of his Therapeutica devoted to methods of treatment of painful conditions

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resulting from blockages of juices or air in the body caused by phlegm, recommends the application of a certain number of remedies that will be able to penetrate the body and remove the obstruction. Among them, along with potions such as baking soda (sodium bicarbonate) mixed with a small, though unspecified, amount of honey and vinegar, or sheep bile with oil, there is also a recommendation for a liquid or semi-liquid medication, depending on the proportions, made of onion juice and honey (Alex., Ther. 73.20, vol. 2). The discussed vegetable was mentioned by Alexander together with spikenard (Nardostachys jatamansi [D. Don] DC.), rue (Ruta graveolens L.) cooked in oil, pepper (Piper nigrum L.) with oil, resin spurge (Euphorbia resinifera A. Berger), garlic, leaves of the bay laurel (Laurus nobilis L.), marjoram (Origanum majorana L.) or orris oil and other products in another fragment devoted to otalgia caused by cold, wet and windy weather when he advised the application of various heating remedies (Alex., Ther. 77.9–18, vol. 2). Elsewhere in his work Therapeutica, when describing simple medicaments recommended in the treatment of alopecia areata, Alexander of Tralles encouraged patients to rub the affected areas with radish (Raphanus sativus L.) and a cut onion (Alex., Ther. 443.9–23, vol. 1). When writing his long passage on hair loss not related to alopecia areata but resulting from the loose nature of skin pores or the secretion (evaporation) of moist substances through the skin, the same author recommended the use of remedies with cooling and tightening properties combined with food products without bitterness and not widening or opening the pores. He classified rocket salad (Eruca sativa Mill.), garden cress (Lepidium sativum L.), leek, onion and garlic as representatives of the same foods. As Alexander believed, all of them cause the thickening and blockage of skin pores that are desirable in the case of the discussed problem (Alex., Ther. 447.23–449.3, vol. 1). To complete the summary of the oeuvre of the author of Therapeutica concerning medical applications of onion, it is worth adding that he provided information on explicit contraindications to its use. It is included in a fragment of the chapter on epilepsies in which, among others, food products recommended and not recommended to patients are described. Allium cepa is mentioned here, along with Athamatha L. i Smyrnium perfoliatum Mill., duck meat and other types of food (Alex., Ther. 543.9– 14, vol. 1). In his treatise, Paul of Aegina presented brief characteristics of the onion’s properties, demonstrating a far-reaching convergence with his predecessors. Just like them, he put onion in the same line with garlic and leek, describing it as a pungent vegetable which warms up the body, and thins and cuts its bad humours (Paul, Epit. 1.76.1.16–19). If cooked twice,

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it provides little nutrition to the body. When it remains raw, however, it does not nourish at all (Paul, Epit. 1.76.1.19–20). Additional information on the onion’s properties may be inferred from Paul of Aegina’s general opinion on the group of vegetables he placed the onion in. On these grounds it appears as a plant that should be consumed because it provides better juices to a consumer’s organism. When prepared in brine or vinegar and salt, it soothes the stomach, stimulates appetite and cuts humours. At the same time, though, it is difficult to digest if eaten in excess (Paul, Epit. 1.76.1.23–25). We can read in Epitome that onion is a heating substance of the 4th degree, as it consists of thick matter. Moreover, it has cleansing effects and, mixed with vinegar, it removes rash (alphós) (Paul, Epit. 7.3.10.360–361), whereas when used in the case of alopecia areata it results in faster hair growth than alcyonium (Paul, Epit. 7.3.10.361–362), mentioned by the other authors. Finally, onion juice is a medication for people with impaired vision due to the inflow of thick juices to the eyes (Paul, Epit. 7.3.10.362–363). In order to supplement the information presented above, it is worth referring to the already mentioned Latin texts which, although they are not specialised medical treatises (except the work written by Anthimus), still contain a lot of valuable information constituting, at least partially, a clear parallel to the findings of Greek medicine. Some information on the medical applications of onion was handed down by Celsus. According to his De medicina, he described the vegetable as containing bad juices, like a whole range of other aliments made from plants, including garlic and leek, which are often classified as falling into the same group as Allium cepa (Cels., Med. 2.21.1). Moreover, it is a pungent (Cels., Med. 2.22.1), heating (Cels., Med. 2.27.1) and diuretic (Cels., Med. 2.31.1) agent and has a positive effect on digestion (Cels., Med. 2.29.1). Onion causes (obviously after being consumed) flatulence (Cels., Med. 2.26.1). In the opinion of Celsus, the drying and heating properties of onion were useful in the treatment of diseases related to the heart and circulatory system. Since one element of recommended therapy then was a proper diet (it means the selection and dosage of ingredients, including wine), in the case of problems with food intake it was advised to cover the patient’s abdomen with crushed onion so that the stomach could retain drunk wine, and the function of the intestines and blood vessels could be stimulated (Cels., Med. 3.19.2). The discussed vegetable was to be chewed also in the case of tongue paralysis (Cels., Med. 4.4.1), whereas women were supposed to eat it if they wanted to trigger menstruation (Cels., Med. 4.27.1).

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We may find plenty of relevant data concerning the medical properties of onion in the works of Pliny. According to his claims, it was believed that regular consumption of cooked onion, which could be sweetened with honey, helped to maintain good bodily health and strength as well as get rid of cough (Pliny, HN 20.20.42). Chewing onion together with some bread, on the other hand, was helpful in oral ulceration (Pliny, HN 20.20.39). It was also believed that eating onion had a positive effect on the organs located in the chest and on the digestion processes (by relaxing and cleansing the intestines) (Pliny, HN 20.20.42). However, it may cause flatulence and thirst (Pliny, HN 20.20.42). As far as Pliny is concerned, onion also has many external applications. Inhaling the onion smell in order to induce irritation and watering of the eyes, as well as instilling drops of squeezed onion juice into the eyes were believed to be helpful in the case of vision problems (Pliny, HN 20.20.39). Fresh vegetables with vinegar or dried with wine and honey should be applied on the areas where skin was affected with a dog bite and kept there for several days (Pliny, HN 20.20.39). An onion grated or roasted in ash and then mixed with vinegar was considered to be helpful in the case of a viper or spider bite (Pliny, HN 20.20.41). When mixed with honey or vinegar and applied to wounds, it was supposed to stimulate the process of healing, just like dried onion mixed with honey and wine (Pliny, HN 20.20.39). Cut onion was rubbed into the skin of those people who tried to eliminate alopecia areata or psoriasis; in its cooked variant it was used in the same way to relieve dysentery or lumbago (Pliny, HN 20.20.41). Onion juice was used as a rub in the case of tonsillitis (it could be mixed with rue and honey), vision problems and purulent inflammation of the parotid glands (Pliny, HN 20.20.39–42), as well as a mouth rinse alleviating toothache (Pliny, HN 20.20.41). Together with human milk it brought relief to earache, and in the case of hearing problems it was to be applied, with some goose fat, in the ears (Pliny, HN 20.20.40). Diluted with water it was believed to help people who suddenly lost their ability to speak (Pliny, HN 20.20.41. It is hard to explain what precisely caused loss of voice in this case). And finally, when mixed with fennel (Foeniculum vulgare Mill.) onion juice was an effective remedy in the initial stage of oedema (Pliny, HN 20.20.43). Fragments taken from Gargilius, a kind of summary of the crucial findings made by earlier Greek authors and by Pliny, were interesting proof of ancient opinions about the onion among people who touched on medical issues as amateurs. Gargilius began with a discussion of the properties of the vegetable, at the same time indicating that the former medical authorities he was referring to had not developed a clearly

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positive or negative picture of the onion’s effect on the body. Therefore, he presented some information indicating that Allium cepa eaten every day enables people to maintain good health, improves digestion, and causes no harm except in the case of people who suffer from an excess of bile. On the other hand, though, onion causes flatulence and thirst as well as triggering the feeling of heaviness in the head (Garg., Med. hol. 27.2–7). As for strictly internal applications, the author of Medicinae ex holeribus et pomis wrote that if someone wanted to eliminate oral ulcers, chewing onion with bread was recommended (Garg., Med. hol. 27.8); he also mentioned that eating cooked onion with oil spread eases suffering caused by diarrhoea (Garg., Med. hol. 27.18). Soaked in vinegar, cooked in wine and honey, mixed with salt and rue, or dried and mixed with honey, onion was a remedy applied in the treatment of injuries caused by dog bites (Garg., Med. hol. 27.8–12). Rubbed onto skin, it was once again recognised as an effective agent against hair loss problems (Garg., Med. hol. 27.19–20. Gargilius added, like his predecessors, that onion is more effective than alcyonium in this case). Gargilius also informs that onion juice added to human milk and applied into the ears soothes earaches (Garg., Med. hol. 27.13). Drinking pure juice helps women struggling with irregular, late periods (Garg., Med. hol. 27.16), and applying it when mixed with hen’s fat onto grazed skin of the feet brings them relief (Garg., Med. hol. 27.17). At the end it is worth quoting yet another opinion on the onion, a Latin one although written by Anthimus, a Greek physician working in the West at the court of King Theodoric the Great (died in 526). He wrote a few words about the described vegetable in his small treatise De observatione ciborum. His specification is limited only to the statement that onions contribute to moisture production. He contends that their Ascalonian variety is better in this respect (Anth., Obs. cib. 62), which means that this variety contributes to the phenomenon to a lesser extent. To sum up, four issues are worth emphasising. Firstly, the onion was a vegetable which, in light of the analysed treatises, was used in medicine during the whole period under study. There is no denying that information on the subject included in Greek works created after Galen gets shorter and shorter as well as less and less detailed. However, it should be attributed to a general tendency that involved a shortening of the source material, such as Galen’s oeuvre, by authors like Oribasius, Aetius, Anthimus or Paul of Aegina – which should by no means be associated with a gradual decrease of the importance of the onion in medical care. The same applies to the discussed Latin treatises: for Gargilius, the most important source of information seems to be Pliny – though he owed part

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of his knowledge to Greek authors, including Galen, too – but it does not change the general tendency of his style to abbreviate disquisitions of his predecessors. This tendency makes his work similar to Greek medical treatises written after Galen. Secondly, doctrine on the dietary properties and medical applications of the onion (to the extent that we may get knowledge about it based on the treatises preserved to our times) was finally established in the 2nd century by Galen, with the participation of renowned authors from earlier times, and actually remained unchanged until the end of the period we have studied – i.e. for the next 500 years. Moreover, its influence crossed the borders of the Greek language circle since it is present also in the work of Latin authors. Thirdly, the onion was applied in the treatment of many health problems nowadays classified as representing different branches of medicine. In the sources there prevail descriptions of the discussed vegetable used in dermatology, otolaryngology and ophthalmology, whereas references to its application in ailments of a different nature are found quite rarely. Fourthly, the case of the onion is not unique as compared to other varieties of vegetables, or in broader terms, edible plants in general. It should be stressed that, on the contrary, it appears as a typical one for ancient and early Byzantine medicine based to a large extent on treatment using natural components, very often commonly available and perfectly known to patients in everyday life as food products. In the treatises analysed, the onion appears side by side with other vegetables, very often in one group with garlic or leek, lying close to considerations over cereals, leguminous plants or fruits. It is not possible to claim that in the sources analysed Allium cepa is distinguished among other plants by its significantly broader application, or that it is recommended for an exceptionally vast number of ailments, or that it is a component of an extraordinarily great amount of medications, being almost a panacea. In this respect, it undoubtedly gives way to numerous cereal products, as well as to certain species of vegetables like the cabbage (Kokoszko, Jagusiak and RzeĨnicka 2014, 191-245; 399-432; Jagusiak 2014b, 176-183).

References Primary sources Aet., Iatr. – Aetii Amideni libri medicinales I–VIII, edidit Alexander Olivieri. Lipsiae – Berolini: Teubner, 1935-1950. Alex., Ther. – Alexandri Tralliani Therapeutica, in Alexander von Tralles, vol. I–II, edidit Theodor Puschmann. Wien: Braumüller, 1878.

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Anth., Obs. cib. – Anthimus, On the observance of foods. De observatione ciborum, edited by Mark Grant. Totnes – Blackawton: Prospect Books, 2007. Cels., Med. – Celsus, De medicina with an English translation in three volumes, translated by Walter G. Spencer. London: Heinemann, 19351938. Columella, De re rustica – Lucius Iunius Moderatus Columella, On agriculture in three volumes, vol. I, translated by Harrison Boyd Ash. London – Cambridge, Mass.: Harvard University Press, 1960; vol. II– III, translated by Edward S. Forrester and Edward H. Heffner. London – Cambridge, Mass.: Harvard University Press, 1954-1955. De re cocq. – Apicius. A critical edition with an introduction and an English translation of the Latin recipe text Apicius, edited by Christopher Grocock and Sally Grainger. Blackawton – Totnes: Prospect Books, 2006. Diosc., De mat. med. – Pedanii Dioscuridis Anazarbei De materia medica libri V, vol. I–III, edited by Max Wellmann. Berolini: Weidmannsche Buchhandlung, 1906-1914. Diosc., Simpl. med. – Dioscuridis Peri haplon farmakon, edited by Max Wellmann. Berolini: Weidmannsche Buchhandlung, 1914. Gal., Alim. fac. – Galeni De alimentorum facultatibus libri III, in Claudii Galeni opera omnia, vol. VI, edidit Carl G. Kühn. Lipsiae: Cnoblochii, 1823. Gal., Comp. med. – Galeni De compositione medicamentorum secundum locos libri X, in: Claudii Galeni opera omnia, vol. XII, edited by Carl G. Kühn. Lipsiae: Cnoblochii, 1827, 378-1007; vol. XIII, edidit Carl G. Kühn. Lipsiae: Cnoblochii, 1827, 1-361. Gal., Bon. maliq. – Galeni De bonis malisque sucis, edidit Georg Halmreich, in Corpus medicorum graecorum, vol. IV, 2, Lipsiae – Berolini: Teubner, 1923. Gal., Sanit. – Galeni De sanitate tuenda libri VI, in Claudii Galeni opera omnia, vol. VI, edidit Carl G. Kühn. Lipsiae: Cnoblochii, 1823, 1-452. Gal., Simpl. med. – Galeni De simplicium medicamentorum temperamentis ac facultatibus libri XI, in Claudii Galeni opera omnia, vol. XI, edited by Carl G. Kühn. Lipsiae: Cnoblochii: 1826, 379-892; vol. XII, edidit Carl G. Kühn. Lipsiae: Cnoblochii: 1827, 1-377. Gal., Vict. att. – Galeni De victu attenuante, edidit Karl Kalbfleisch, in Corpus medicorum graecorum, vol. IV, 2, Lipsiae – Berolini: Teubner, 1923.

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Garg., Med. hol. – Q. Gargilius Martialis, Medicinae ex holeribus et pomis, texte, traduction et commentaire par Brigitte Maire. Lausanne: Lausanne University, 2001. Geoponica – Geoponica sive Cassiani Bassi Scholastici De re rustica eclogue, edidit Heinrich Beck. Lipsiae: Teubner, 1895. Orib., Coll. med. – Oribasii collectionum medicarum reliquiae, vol. I–IV, edidit Johann Raeder. Lipsiae – Berolini: Teubner, 1928-1933. Orib., Syn. – Oribasii synopsis ad Eustathium filium, in Oribasii synopsis ad Eustathium filium et libri ad Eunapium, edidit Johann Raeder. Lipsiae: Teubner, 1964. Palladius, Opus agriculturae – Palladii Rutilii Tauri Aemiliani viri ilustris opus agriculturae, de veterinaria medicina, de institutione, edited by Robert H. Rodgers. Leipzig: B. G. Teubner, 1975. Paul, Ep. – Paulus Aegineta, edidit Johann L. Heiberg. Lipsiae – Berolini: Teubner, 1921-1924. Pliny, HN – Pliny, Natural history, vol. I–X, translated by Horace Rackham, William H. S. Jones and D. E. Eichholz. Cambridge, Mass.: Harvard University Press, 1938-1963. Theophrastus, HP – Enquiry into plants and minor works on odours and weather signs, vol. I–II, edited by Arthur Hort. London – Cambridge, Mass.: Heinemann, 1916.

Secondary Sources Abdel-Maksoud, Gomaa and El-Amin Abdel-Rahman. 2011. “A Review of the Materials used During the Mummification Processes in Ancient Egypt.” Mediterranean Archaeology and Archaeometry 11, no. 2: 129150. Alcock, Joan P. 2006. Food in the Ancient World. Westport – London: Greenwood. Anagnostakis, Ilias. 2013a. “Byzantine Delicacies.” In Ilias Anagnostakis (ed.), Flavours and Delights. Tastes and Pleasures of Ancient and Byzantine Cuisine, 81-103. Athens: Armos. Anagnostakis, Ilias. 2013b. “Byzantine Diet and Cuisine. In Between Ancient and Modern Gastronomy.” In Ilias Anagnostakis (ed.), Flavours and Delights. Tastes and Pleasures of Ancient and Byzantine Cuisine, 43-69. Athens: Armos. André, Jacques. 1956. Lexique de termes de botanique en latin. Paris: C. Klincksieck. André, Jacques. 1967. Les noms d’oiseaux en latin. Paris: C. Klincksieck.

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Baldwin, Barry. 1975. “The Career of Oribasius.” Acta Classica 18: 8597. Bednarczyk, Andrzej. 1995. Galen. Gáówne kategorie systemu filozoficzno-lekarskiego. Warszawa: Wydawnictwo Uniwersytetu Warszawskiego. Bonet, Valérie. 1995. “Traditions populaires et sources écrites médicales. L’exemple de Gargilius Martialis.” Cahiers d’Histoire des Techniques 3: 139-157. Brewster, James L. 2008. Onions and Other Vegetable Alliums. Wallingford, Cambridge, Mass.: CABI. Chroboczek, Emil. 1970. Cebula. Warszawa: PaĔstwowe Wydawnictwo Rolnicze i LeĞne. Crum, Earl LeV. 1932a. “Diet in Ancient Medical Practice as Shown by Celsus in his De Medicina.” The Classical Weekly 25, no. 20: 153-159. Crum, Earl LeV. 1932b. “Diet in Ancient Medical Practice as Shown by Celsus in his De Medicina (continued).” The Classical Weekly 25, no. 21: 161-165. Dalby, Andrew. 2003. Food in the Ancient World from A to Z. London, New York: Routledge. Denham, Alison and Midge Whitelegg. 2014. “Deciphering Dioscorides: Mountains and Molehills?” In Susan Francia and Alison Stobart (eds.), Critical Approaches to the History of Western Herbal Medicine: From Classical Antiquity to the Early Modern Period, usan Francia and Alison Stobart 191-209. London: Bloomsbury. Duffy, John. 1984. “Byzantine Medicine in the Sixth and Seventh Centuries. Aspects of Teaching and Practice.” Dumbarton Oaks Papers 38: 21-27. Fagan, Garrett G. 2006. “Bathing for Health with Celsus and Pliny the Elder.” The Classical Quarterly 56, no. 1: 190-207. Debru, Armelle (ed.). 1997. Galen on Pharmacology, Philosophy, History and Medicine. Proceedings of the Vth International Galen Colloqium, Lille, 16-18 March 1996. Leiden, New York: Brill. Garnsey, Peter. 2002. Food and Society in Classical Antiquity. Cambridge: Cambridge University Press. Garzya, Antonio. 2005. “Alexander v. Tralles.” In Antike Medizin. Ein Lexikon, herausgegeben von Karl-Heinz Leven, 27-28. München: C. H. Beck. Hankinson, Robert J. (ed.). 2008. The Cambridge Companion to Galen. Cambridge: Cambridge University Press. Healy, John F. 2000. Pliny the Elder on Science and Technology. Oxford: Oxford University Press.

The Onion (Allium cepa L.) in Late Ancient and Early Byzantine Medical Literature (I-VII c. AD)

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Jagusiak, Krzysztof. 2014a. “Cebula.” In Maciej Kokoszko (ed.), Dietetyka i sztuka kulinarna antyku i wczesnego Bizancjum (II–VII w.), cz. 2, Pokarm dla ciaáa i ducha, , 203-207. àódĨ: àódĨ University Press. Jagusiak, Krzysztof. 2014b. “Kapusta.” In Maciej Kokoszko (ed.), Dietetyka i sztuka kulinarna antyku i wczesnego Bizancjum (II–VII w.), cz. 2, Pokarm dla ciaáa i ducha, 176-183. àódĨ: àódĨ University Press. Jagusiak, Krzysztof and Maciej Kokoszko. 2011. “ĩycie i kariera Orybazjusza w Ğwietle relacji Ĩródáowych.” Przegląd Nauk Historycznych 10, no. 1: 5-21. Koder, Johannes. 1993. Gemüse in Byzanz. Die Versorgung Konstantinopels mit Frischgemüse im Lichte der Geoponika. Wien: Fassbaender. —. 2013. “Everyday Food in the Middle Byzantine Period.” In Ilias Anagnostakis (ed.), Flavours and Delights. Tastes and Pleasures of Ancient and Byzantine Cuisine, 139-156. Athens: Armos. Kokoszko, Maciej. 2011. “Smaki Konstantynopola.” In Mirosáaw J. Leszka and Teresa WoliĔska (eds.), Konstantynopol – Nowy Rzym. Miasto i ludzie w okresie wczesnobizantyĔskim, a WoliĔska, 471-575. Warszawa: PWN. Kokoszko, Maciej and Krzysztof Jagusiak. 2011. “Warzywa w kuchni i dietetyce póĨnego antyku i wczesnego Bizancjum (IV–VII w.). Perspektywa konstantynopolitaĔska.” Piotrkowskie Zeszyty Historyczne 12: 34-52. Kokoszko, Maciej, Krzysztof Jagusiak and Zofia RzeĨnicka. 2014. Cereals of Antiquity and Early Byzantine Times. Wheat and Barley in Medical Sources (Second to Seventh Centuries AD). àódĨ: àódĨ University Press. Korpanty, Józef (ed.). 2001. Sáownik áaciĔsko-polski. Warszawa: PWN. Kroll, Wilhelm. 1951. “Plinius (5).” In Realencyclopädie, Bd. XXI, 1, 271-439. Stuttgart: Alfred Druckenmüller. Krynicka, Tatiana. 2015. “Kwintus Gargiliusz Marcjalis w Ğwietle Ĩródeá epigraficznych.” Nowy Filomata 19, no. 2: 182-198. Lehmann, Hermann. 1930. “Zu Aëtius Amidenus.” Sudhoffs Zeitschrifft für Geschichte der Medizin 23: 205-206. Liddell, Henry G., and Robert Scott (eds.). 1996. A Greek-English Lexicon. Oxford: Clarendon Press. López Pérez, Mercedes. 2010. Ginecología y patología sexual femenina en las Colecciones Médicas de Oribasio. Oxford: BAR. Maáachowski, Antoni. 1977. Warzywa cebulowe. Warszawa: PaĔstwowe Wydawnictwo Rolnicze i LeĞne.

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Chapter Seven

Nauert, Charles G. 1980. “C. Plinius Secundus Naturalis historia.” Catalogus Translationum et Commentariorum 4: 297-422. Nehring, Edward. 1923. Cebula oraz warzywa pokrewne. Warszawa: KsiĊgarnia Rolnicza. Nutton, Vivian. 1984. “From Galen to Alexander. Aspects of Medicine and Medical Practice in Late Antiquity.” Dumbarton Oaks Papers 38: 1-14. —. 1999. “Galen and the Traveler’s Fare.” In John Wilkins, David Harvey and Mike Dobson (eds.), Food in Antiquity, , 359-370. Exeter: University of Exeter Press. Pape, Wilhelm. 1908. Griechisch-deutsches Handwörterbuch, Bd. I. Braunschweig: Vieweg Werlag. Plezia, Marian (ed.). 2007. Sáownik áaciĔsko-polski. Warszawa: PWN. Pormann, Peter E. 2004. The Oriental Tradition of Paul of Aegina’s Pragmateia. Leiden, Boston: Brill. Rice, Eugene F. 1980. “Paulus Aegineta.” Catalogus Translationum et Commentariorum 4: 145-191. Riddle, John M. 1980. “Dioscorides.” Catalogus Translationum et Commentariorum 4: 1-143. —. 1984. “Gargilius Martialis as a Medical Writer.” Journal of the History of Medicine and Allied Sciences 39, no. 4: 408-429. —. 1985. Dioscorides on Pharmacy and Medicine. Austin: University of Texas Press. Salazar, Christine F. 1998. “Getting the Point: Paul of Aegina on Arrow Wounds.” Sudhoffs Archiv 82, no. 2: 170-187. Sarton, George. 1954. Galen of Pergamon. Lawrence: University of Kansas Press. Scarborough, John. 2013. “Theodora, Aetius of Amida and Procopius: Some Possible Connections.” Greek, Roman, and Byzantine Studies 53: 742-762. Schröder, Heinrich O. 1940. “Oreibasios.” In Realencyclopädie der classischen Altertumswissenschaft, Supplementband VII, 797-812. Stuttgart: Metzlerscher. Stannard, Jerry. 1982. “Medicinal Plants and Folk Remedies in Pliny, Historia Naturalis.” History and Philosophy of the Life Sciences 4, no. 1: 3-23. Talbot, Alice-Mary. 2007. “Mealtime in Monasteries: The Culture of the Byzantine Refectory.” In Leslie Brubaker and Kalliroe Linardou (eds.), Eat, Drink, and be Merry (Luke 12:19). Food and Wine in Byzantium. In honour of Professor A. A. M. Bryer, , 109-126. Aldershot: Routledge.

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Thorndike, Lynn. 1964. “Relations between Byzantine and Western Science and Pseudo-science.” Janus 51: 1-47. Wellmann, Max. 1894. “Aetios (8).” In Realencyclopädie der classischen Altertumswissenschaft, Bd. I, 703-704. Stuttgart: Metzlerscher. —. 1905. “Dioskurides (12).” In Realencyclopädie der classischen Altertumswissenschaft, Bd. V, 1125-1143. Stuttgart: Metzlerscher. Zohary, Daniel and Maria Hopf. 1993. Domestication of Plants in the Old World. The Origin and Spread of Cultivated Plants in West Asia, Europe, and the Nile Valley. Oxford: Oxford University Press.



CHAPTER EIGHT THE CHANGING FACE OF GLAUCOMA IN HISTORY TEREZA KOPECKA

Introduction and Background The eye is an extremely sensitive and complex organ, poorly accessible for examination and treatment procedures. But eyesight is the most important of all the five senses and loss of sight is associated with a substantial worsening of quality of life of the affected person and her family. Therefore, ophthalmology has always been one of the most important specialties in medicine. Nevertheless, its scientific development was long and knotty.

Historical Background The opening question became the hardest and an answer was awaited for thousands of years: “How does the eye work?” Many ancient scholars attempted to explain the principle of eyesight, but there were still more questions than answers. Aristotle, Galen, Avicenna – none of them succeeded as they lacked knowledge about the structure of the eye and the physical background of optics. The key discovery was made by the astronomer Johannes Kepler. He managed to explain both refraction within the eye and the perceptive aspect of vision, with the use of Da Vinci’s Camera Obscura (Goes 2013, 164). The cited work was published in 1604 as Ad Vitellionem Paralipomena, Quibus Astronomiae Pars Optica Traditur, in brief Paralipomena. Kepler correctly determined that visual perception is provided by the retina (Goes 2013, 188). But visual acuity engaged people’s attention for a long time before its essence was explained. The history of correction of refractive errors

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started in around 5,000 BC: pieces of glass, transparent pebbles or semiprecious stones were used as reading aids (Cashell 1971). There are multiple theories about the invention of spectacles, but none of them is apparently more convincing than others (Roman 1993). This first mention of any kind of ophthalmic surgery (precise couching of cataractous lenses) can be found in The Code of Hammurabi, which is dated to the 18th century BC. It was performed with the use of bronze needles with decorated handgrips. These needles remained in use for centuries – in ancient Greece and Rome, medieval (Arab) Alexandria and Europe until the 18th century AD, when couching was replaced by extraction of cataractous lenses (Dolezalova 2003, 12–14). Ophthalmic surgeries have always been perceived as extraordinary actions and were frequently portrayed by artists (Dolezalova 2003, 52). The price of an eye was very high. The Code of Hammurabi under number 218 states: “If the surgeon has made a deep incision in (the body of) a (free) man with a lancet of bronze and causes the man’s death or has opened the caruncle in (the eye of) a man and so destroys the man’s eye, they shall cut off his fore-arm.” It must be said that slaves were not equally defended. In the case of damage to a slave’s eye, the physician was forced to render his owner a healthy slave, but he was not punished (Nagarajan 2011). Knowledge about eyesight was not only used, but also abused – at least to the same degree. Since antiquity, blinding was a tool of revenge, punishment or elimination of rivals or enemies. Then, during the Middle Ages, it took the form of a legal penalty, ordered by organs of state power (Buettner 2009) and performed by executioners. This profession was closely related to another one – healing;eExecutioners knew far more about human anatomy than anyone else (Davies and Matteoni 2017). After all, this was the way in which the famous Andreas Vesalius received his first knowledge about the human body, as he spent his childhood in the immediate proximity of an execution ground (Nuland 2000, 114). Despite the long existence of ophthalmology, the majority of its actual expertise was developed after the beginning of the Industrial Revolution. Proper understanding of physiology and pathology of the eye is not possible without modern examination methods (refractometry, ultrasonography, histology, OCT and many others) that demand accurate instrumental facilities. Ophthalmic surgery (precisely surgery of the eyeball) was limited to couching even in the era of John Taylor (17031722). This procedure consisted in the mechanical disruption of supportive fibres and the subsequent dislocation of the opaque lens out of the visual field. Due to lack of knowledge about the eye and the rules of asepsis,

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couching had an up to 80% risk of complications (Dolezalova 2003, 79). Besides, the majority of the Czech population was not used to visiting ophthalmologists until the middle of the 20th century. Refractive errors remained uncorrected due to a negligible degree, the unfavourable cosmetic effect of spectacles (especially in women), or want of money. Some people used the services of clockmakers, who were able to manufacture aids of optic glass (Dolezalova 2003, 166).

Blindness: Illness or a Godly Punishment? Sudden loss of eyesight is a dramatic event with a strong emotional impact on the affected person (Thombs and de Board 2016) and its traditional popular interpretation corresponded with this perception. It was explained as a punishment for blasphemy, a false oath or breaking ethical rules in general. In classical mythology, sudden-onset blindness expresses godly punishment or godly intervention in human actions – for example Erymanthos, who was blinded after his sighting of Aphrodite in a bath (Fontenrose 1981, 144) or Poseidon, who laid a mist before the eyes of Achilles to prevent him from killing Aeneid (Kellenberger 2017, 16). The deep-rooted formulation “make me blind if I lie” expresses an expectation of blindness as a godly punishment for a false oath. Its origin is surprisingly old – its proclamation and subsequent fulfilment are mentioned in the biography of St. Narcissus, the bishop of Jerusalem, who lived in the 2nd century AD (Jaud 1950, Oct. 29). From the medical point of view, sudden-onset blindness can be divided into fleeting (temporary, fugax) and permanent. In both possibilities, a wide range of causes are taken into consideration, whereas one of the most frequent is glaucoma (MacDonald 1965).

Sea Water and Owls It is beyond doubt that glaucoma has accompanied the human race throughout its existence, but the first mention in historical sources can be found in the Hippocratic Corpus, which was written in around 400 BC. The term glaykoseis means elderly-onset blindness, associated with a bluish colour of the pupil. It seems evident that the origin of the word glaucoma dwells in the bluish-green colour of the pupil (glaucos = green) and most authors adhere to this explanation, but in fact this connection cannot be decidedly confirmed. There is a possibility that the term emerged from the other meaning of the Greek word glaukos = owl. An eye afflicted by glaucoma can truly obtain an appearance resembling an owl’s

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eye – big, glossy and shiny – especially in children with inborn glaucoma (Tsatsos and Broadway 2007).

Treatment: An Outline The first recognition of glaucoma was based exclusively on clinical observation. Ancient physicians knew nothing about its causes or pathogenesis nor were they able to distinguish it from other illnesses; Hippocratic glaykoseis encompassed glaucoma, cataract and other clinical conditions (Tsatsos and Broadway 2007). Later authors were all at sea as well. The most frequent terms used for pathological changes observed in glaucoma were “hardening” or “desiccation”. Demosthenes, Rufus of Ephesus and Galen were involved in the bluish colour of the pupil, but clinical observations provided them with data they were not able to interpret. For instance, Galen took notice of glaucoma that occurs as a consequence of couching, but he concluded that it was caused by draining too much liquid from the eye and a subsequent desiccation of the lens (C. Leffler 2015). The key to glaucoma was found much later. Medieval Arab physicians believed that glaucoma (zarqaa in Arab – see Leffler, “What was Glaucoma Called Before the 20th Century?” 2015) is associated with increased intraocular pressure and Richard Banister confirmed their presumptions in 1622. He unambiguously distinguished glaucoma from cataract and described the hardening of the eye that accompanies it. In the 17th century a new era started, which was characterised by the development of multiple theories about the origin and treatment of glaucoma and culminated in the second half of the 19th century (Grom 1979). Some theories had a true basis, but others were false – e.g. Malpighi’s model-study based suggestion about enlargement of the lens, or degeneration of the vitreous body, which was proposed by Brisseaux (Ruzickova 2000, 12). Ocular hypertension was accepted as the cause of glaucoma in 1818 (Duke-Elder and Jay 1969), but the effort to apply this principle to all patients was fruitless. Physicians knew very well that certain patients have a normal intraocular pressure. Albrecht von Graefe published his opinions about this phenomenon, but he provoked strong opposition from experts and was forced to recant them (Singh 2008). A hundred years later, in the mid-twentieth century, physicians still could not be rid of the tight association between ocular hypertension and glaucoma. The diagnosis of “normal tension glaucoma” was then called “pseudoglaucoma” (Birge 1962) which means “false glaucoma”. With centuries of futile effort to find the key to glaucoma, it won a mysterious reputation. Part of the mystery remains until the present day –

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in primary glaucoma (as well as in other primary conditions) we are still not aware of all the factors that trigger the onset of the disease.

The Oldest Treatment: Keep Calm The life of people suffering from glaucoma and the clinical course and prognosis of their disease have changed dramatically during the last 170 years, as new diagnostic and treatment methods have been made available. Initial nihilism was a natural consequence of insufficient knowledge about the illness and an inability to take an active stand. Patients suffered from painful attacks of increased ocular pressure, their eyesight was gradually impaired during these and the vitreous body went cloudy. Blurred vision (especially in the mornings) and rainbow circles around lights are among the typical symptoms of untreated glaucoma. In the end, patients went blind (Chalupecky 1905). The first step towards a real solution was rest regime: its purpose dwells in lowering the activity of the sympathetic nervous system by stress avoidance. High sympathetic activity is associated with an increase of intraocular pressure (Jimenez and Vera 2018) and a worsening of the condition. This treatment approach was later supplemented by efficient drug therapy.

Drug Therapy: Let It Flow The writings of Cornelius Celsus and Rufus of Ephesus mention a recipe called “acroco” – eyedrops containing opium, which were used to ease pain caused by an acute glaucoma attack (Kovarova 2006, 10). It was certainly not a causative therapy, but it was correctly aimed to suppress one of the most troublesome symptoms. The real historical watershed was represented by the introduction of parasympathomimetics into clinical practice. This drug class induces miosis and thus releases the outflow of liquid from the anterior chamber. The first drug to treat glaucoma was physostigmine, which was initially known as “eserine”, successfully tested by Ludwig Laqueur in 1875 (Patil 2012, 110): it is an indirectly acting parasympathomimetic obtained from Calabar beans (Physostigma venenosum). It was also described as a potent antidote of atropine (Nickalls and Nickalls 1988). Nowadays, probably due to the significant side effects and the wide selection of available drugs, it is not routinely used to treat glaucoma. In the Czech Republic it has been registered to treat post-surgery complications and atropine intoxication (www.sukl.cz). Pilocarpine, an alkaloid with a parasympathomimetic effect, has remained in clinical use

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since the 19th century: it was isolated from a South American shrub called Pilocarpus jaborandi. Dr. Symphronio Coutinhou observed hypersalivation in Brazilian natives chewing Pilocarpus leaves, so he took a specimen to Europe in 1873. During the following year, pilocarpine was isolated by A. W. Gerrard, the head pharmacist of University College Hospital in London (Kremer 1986), and independently by E. Hardy in France. Pilocarpine stimulates miosis, which increases outflow from the anterior chamber. Its potency in decreasing the intraocular pressure was discovered in 1877 (Sneader 2005, 98). The story of acetazolamide is also very interesting. In 1940, the diuretic effect of sulphonamides was studied at the University of Cambridge. These drugs are known as safe and effective antibiotics nowadays (one of the most important classes of antibiotics), but then they were found to inhibit the enzyme carboanhydrase, expressed in proximal tubuli; thus, they stop reabsorption of liquid from the proximal tubulus. This is how proximal tubulus diuretics emerged. The same enzyme called carboanhydrase takes part in the secretion of anterior chamber liquid; is action is the same (pump), but the position of protein is inverted. When inhibited by acetazolamide (from the class of sulphonamides), secretion stops and the patient feels significant relief from the symptoms of glaucoma (Sneader 2005, 390). Acetazolamide has remained in topical and systemic use, especially in acute glaucomas. It has substantial side effects, but during short-time administration it is well tolerated (Zahradnickova 2008, 35). During the 20th century a wide range of new drugs emerged. Most of them treat glaucoma by way of the autonomous nervous system. The actual therapeutic guidelines are complex and take into account various subgroups, additional risks and comorbidities of patients (European Glaucoma Society 2017).

Surgical Treatment: Just Cut it Off The oldest surgical procedures aimed to treat glaucoma were based on opening the anterior chamber of the eye. By draining excessive liquid, the pressure decreases. The first technique was a simple puncture, but it is not sufficient in most patients. The eye quickly returns to the previous condition, pressure increases and complications of fast decompression can be very serious: cataract, choroid disruption, hypotonic maculopathy, etc. Nevertheless, this procedure is still performed in some parts of the world to provide immediate relief from symptoms of acute angle-closure glaucoma (Cioboata 2014).

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The beginning of targeted surgical treatment of glaucoma is dated to the year 1857, when Albrecht von Graefe started performing peripheral iridectomy. By exciding a segment of the iris, iridectomy enhanced outflow from the anterior chamber. The pupil thus obtained a shape resembling a keyhole. Iridectomy was usually performed in the upper segment, where the cosmetic effect is (thanks to the covering eyelid) more favourable (Springer 1920, 609). Unfortunately, the effect of iridectomy was temporary, which resulted in restricting its indication to acute glaucomas (Lagrange 1922; Vasek 1924). In 1869, the French oculist Louis de Wecker described anterior sclerectomy, which drained excessive liquid to the subconjunctival space. Long-term results were far better and the method was recognised as suitable for the treatment of chronic glaucoma (Lagrange 1922). During the 20th century, several novel procedures were introduced into routine practice – e.g. trabeculectomy, shunt implantation or ciliary body destruction. Apart from “bloody” techniques, laser “non-bloody” procedures are performed (Razeghinejad and Spaeth 2011). They promise a comfortable perioperational period, long-lasting effects and lower risk of complications.

Case Study: From Blindness to Health Angle-closure glaucoma has a complex and unclear heredity (Wiggs and Paquale 2017), which can be demonstrated in certain cases, and it is heredity that helps us to uncover the diagnosis with a long time gap. This statement can be well demonstrated thanks to a Czech family (their name is not mentioned due to GDPR) that possesses a detailed chronicle, written in the Czech language and containing data about angleclosure glaucoma among its members since the first half of the 19th century. The chronicle has been deposited by its Norwegian descendants and was digitized in 2018. The chronicle provides phenotypic information, not genotypic, but changes in life with glaucoma are still evident, both in the perception and progression of the illness.

The First Mentioned Person is Jan (1803-1863) Jan was a farmer in Ovþáry u Kolína (now the Czech Republic). According to the chronicle, Jan’s wife took care of two sick soldiers who came begging for help. Reportedly, the soldiers were members of the Napoleonic army, but the events described occurred in 1838, decades after

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the end of the Napoleonic wars. Both soldiers suffered from tyfus (typhoid fever) and passed it onto the farmer’s fifteen-year-old son, who soon succumbed to the infection. In the Czech language the word “tyfus” has two meanings: typhoid fever and typhus. In this case, the illness described was probably typhoid fever, because the spreading of typhus demands the presence of a vector, which is the body louse (Pediculus humanus corporis). In the case of body lice being present in the environment, there are usually more persons infected – typhus has a truly epidemic character, which is also expressed by one frequently used term – “epidemic typhus”. The tragedy occurred on a Sunday, when the village square was full of people just leaving church. Jan darted out of his house and put a heavy curse on God. Immediately after that, he was struck blind. In medical terminology, the situation was this: after the tragic loss of his only son, Jan went through an episode of extreme emotional strain, which led to a severe attack of peracute glaucoma, followed by acute loss of sight, which was, due to the absence of any therapy, permanent. Thanks to his supportive family, Jan had a good quality of life even after that. He lived to the age of sixty years and had another two children: a son, named Vaclav, and a daughter, Anna. In the chronicle, Jan is the last representative of the era when ocular diseases were attributed a mystic meaning, as diagnosis was primitive (if it was performed) and therapy usually absent.

Jan’s Son Vaclav (1843-1912) Vaclav suffered from a serious ocular injury as a child. The affected eye went blind and the fellow eye was afflicted by almost complete loss of sight after unsuccessful surgery. This picture indicates that he might have suffered from posttraumatic glaucoma, which results in contralateral openangle glaucoma in 50% of cases (Tesluk and Spaeth 1985). Vaclav’s case is not helpful for this work, as his injury acts as a significant confusing factor that thwarts the effort to assess his phenotype, although he proves that in the second half of the 19th century, it was not impossible to undergo specialised surgery.

Jan’s Daughter Anna (1846-1934) Anna suffered from glaucoma since her forties (the chronicle lines up her symptoms with the period following the birth of her daughter Marie in 1879). In her case, the illness was not ignored and she was followed-up on a long-term basis. Fortunately, the onset of her disease was not peracute as

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in her father. Due to the era, when targeted treatment of glaucoma was not routinely available, she continued to deteriorate still more, until she finally lost her sight as well. But how old was she then? The chronicle describes blind Anna as a modest person who never complained about her fate and learned how to keep the house despite her blindness “so as to satisfy her darling”. The mentioned “darling” was probably her husband – according to other expressions, they had a loving relationship. But if Anna went blind shortly after delivery, the core of this description would probably be focused on her daughter, and baby care is usually the hardest issue for blind women. Due to the absence of such an account, we can assume that complete loss of sight cannot be dated before her fifties, which means the period when her daughter was more than seven years old. Anna lived in the era when glaucoma was well known and diagnosed routinely, but therapy was limited to rest regime.

Anna’s Daughter Marie (1879-1955) Marie observed the first symptoms of glaucoma at the age of 26, when her husband’s candy factory went bankrupt and he committed suicide. A close association with emotional strain (sympathetic stimulation) is present again. Marie decided to visit the renowned specialist in ophthalmology, Professor Jan Deyl. Dr. Jan Deyl (1855-1924) was ranked among the founders of Czech ophthalmology. In 1902 he was appointed Professor of Ophthalmology at Charles University and later achieved fame as an extraordinary philanthropist. He won a reputation as a first-class ophthalmic surgeon and saved the eyesight of thousands regardless of their solvency. He was a lifelong advocate of blind people, a teacher, and the author of many expert articles and several scientific monographs about ophthalmology. In 1909 he co-founded a society for the support of blind people (Moravec 1909) and during the next year he arranged the opening of “Deyl’s Pedagogic Institute” in Prague. The purpose of this organization was to help blind youth to gain craftsmanship and thus become self-sufficient (Unknown 1910). The institute gradually gained musical specialization (Vytlacil 2015) and is still in operation as the Jan Deyl Conservatory and Secondary School for Visually Impaired Students (www.kjd.cz). It continues to be a highly appreciated facility. Prof. Deyl helped with many other important issues – e.g. providing ophthalmological treatment to soldiers, whose sight was impaired on the battlefront of World War I, and sought support for hopeless cases (Unknown 1924). He was very popular among his patients. When he died, it was a sad time for the whole nation.

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A small boy, his former patient, walked for 6 hours in the freezing cold, poorly dressed, to participate in his funeral as one of the altar boys (Dienstbier, Kurz and Matousek 1957, 127). In the first examination, Prof. Deyl underestimated Marie’s condition and told her to come again in 20 years, as she could not have glaucoma at her age. Marie, who saw the development of her mother’s illness, believed she truly had glaucoma. But thanks to the support of her family, the situation calmed down and she recovered for some time. Another episode of extreme emotional strain occurred in 1916, when Marie’s father died. After becoming a widow, she was dependent on his support, as he was the financial provider of her and her three children. As a result, her glaucoma manifested again with its typical symptoms: misty vision in the mornings and rainbow circles around the lights. Her condition quickly worsened and Prof. Deyl performed surgery. Post-operational healing was not possible without rest regime – Marie’s health was dependent on her emotional well-being – but the political situation was not felicitous. Enlistment of sixteen-year-old boys was announced and Marie’s son Karel was hereby called to arms. Marie managed to save him from the pandemonium of World War I, but she couldn’t avoid another exacerbation of her glaucoma. In 1917 she was admitted to hospital again. Deyl offered her surgery that stopped the progression of her disease for twenty years. Marie agreed and the surgery was performed with success. According to expert articles published in the first third of the 20th century, surgical treatment of angle-closure glaucoma was represented by two procedures: iridectomy, which was beneficial in acute glaucoma, and sclerectomy, which was focused on a long-lasting effect in chronic cases (Vasek 1924). The treatment process of Marie was probably identical. In the acute stage an iridectomy was performed, which was later supplemented by sclerectomy. After sclerectomy, she was on the threshold of a long period of remission, which lasted for 22 years. Another exacerbation of her condition occurred at the beginning of World War II, when Marie’s son Josef was incarcerated by the Nazis as a member of the Czech resistance movement. On her return home from Dresden (Josef’s jail) she had an attack of acute glaucoma with sudden-onset blindness. She underwent more surgery, performed by Deyl’s successor Prof. Kadlicky. Her short-lived relief ended with another visit to Dresden, when Marie’s condition worsened again: further procedures failed to help and she suffered from severe pain. The effect of morphine was also short-lived. In the end, Marie chose to undergo an alcohol injection to the optic nerve that guaranteed immediate and permanent relief from pain, but also unilateral blindness. Surprisingly, Marie was happy with this decision, as the relief

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was quick and half-blindness didn’t bother her. The fellow eye is not mentioned again, only in connection with the worsening of her general health condition at the age of approximately 75 years. Marie represents the era when the passive approach towards glaucoma was replaced by therapy that was easily accessible, but its efficiency and comfort were varied.

Marie’s Daughter Vaclava (1903-1994) and Vaclava’s Daughter Hana (*1928) While Vaclava never suffered any symptoms of glaucoma, Hana suffered from angle-closure glaucoma from the age of sixty. Thanks to efficient drug therapy, she is in long-term remission even in her nineties (2018 interview). She does not need any surgical procedure, has no symptoms, and her quality of life is not influenced by glaucoma in any way. The only inconvenience caused by the illness is the necessity of regular follow-up examinations. Members of the younger generations have no symptoms of glaucoma.

Conclusion In the beginning, hereditary glaucoma in this family was interpreted as a godly punishment for Jan’s blasphemy. With time, it became obvious that it had an organic cause, which is not transmitted as a hereditary sin, but as a hereditary illness. When reading this chronicle, we can see with our own eyes the stunning transformation of glaucoma: from a helpless and severely mutilating illness to one that is easily and comfortably treatable, with no unpleasant consequences. The mystery of the family curse has gone. Table: Jan (18031863) Anna (18461934) Marie (18791955)

Diagnostics 0

Therapy 0

Result Acute irreversible loss of sight

Clinical

Rest regime

Loss of sight in her fifties

1. Clinical 2. Non-specified objective tests

1. Rest regime 2. Iridectomy 3. Sclerectomy

Lower progression of the illness, loss of sight in her seventies

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Hana (*1928)

Complex modern testing

Eyedrops

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100% remission

Phenotypic family tree:



Acknowledgement This research wouldn’t have been possible without the kind co-operation of the family described – especially Tarjei C., Ivan P., and Hana P.

References Birge, H. L. 1962. “Pseudoglaucoma”. Trans Am Ophthalmol Soc. 60: 85115. Buettner, J. U. 2009. “The Punishment of Blinding and the Life of the Blind”. Med Ges Gesch. 28: 47-72. Cashell, G. T. 1971. “A Short History of Spectacles”. Proc R Soc Med. Oct. 64(10): 1063-4. Chalupecky, J. 1905. “Glaukom v lekarstvi urazovem”. Casopis lekaru ceskych. 50: 1404. Cioboata, M. et al. 2014. “Benefits of Anterior Chamber Paracentesis in the Management of Glaucomatous Emergencies”. J Med Life. 7 (Special Issue 2): 5-6. Davies, O., and Matteoni, F. 2017. Executing Magic in the Modern Era: Criminal Bodies and the Gallows in Popular Medicine. London (UK): Palgrave Macmillan. doi: 10.1007/978-3-319-59519-1_3.

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Dienstbier, E., Kurz, J., and Matousek, O. 1957. Zakladatele ceske oftalmologie. Prague: Statni zdravotnicke nakladatelstvi. Dolezalova, V. 2003. Mala zastaveni na stezkach dejin ocniho lekarstvi. Ceske Budejovice: A+U Design. Duke-Elder, S., and Jay, B. 1969. Diseases of the Lens and Vitreous: Glaucoma and Hypotony. London: Kimpton. European Glaucoma Society. 2017. “European Glaucoma Society Terminology and Guidelines for Glaucoma.” Br J Ophthalmol. 101(6): 130-195. doi: 10.1136/bjophthalmol-2016. Fontenrose, J. O. 1981. The Myth of the Hunter and the Huntress. Berkeley: University of California Press. Goes, F. J., and De Laey, J. J. 2013. The Eye in History. New Delhi: Jaypee-Highlights Medical Publishers. Grom, E. 1979. “An Essay on the History of Glaucoma”. Hist. ophthal. intern. 1: 55-65. Jaud, L. 1950. Vie des Saints pour tous les jours de l’annee. Mame: Tours. Jimenez, R., and Vera, J. 2017. “Effect of Examination Stress on Intraocular Pressure in University Students”. Appl Ergon. 2018 Feb. 67: 252-258. doi: 10.1016/j.apergo.2017.10.010. Kellenberger, J. 2017. Religious Epiphanies Across Traditions and Cultures. Palgrave MacMillan. Kremer, E. 1986. “Sonnedecker, G. Kremers and Urdang’s History of Pharmacy”. Amer. Inst. History of Pharmacy: 119. Lagrange, F. 1922. “O glaukomu a jeho chirurgickem leceni”. Casopis lekaru ceskych. 25: 561-566. Leffler, C. T. et al. 2015. “What was Glaucoma Called Before the 20th Century?” Ophthalmol Eye Dis. 7: 21-33. doi:10.4137/OED.S3200425673972. —. 2015. “The Early History of Glaucoma: the Glaucous Eye (800 BC to 1050 AD)”. Clin Ophthalmol. Feb. 2; 9: 207-15. doi: 10.2147/OPTH.S77471. MacDonald, A. E. 1965. “Causes of Blindness in Canada: An Analysis of 24,605 Cases Registered with The Canadian National Institute for the Blind”. Canadian Medical Association Journal 92(6): 264-279. Moravec, F. V. 1909. “Zemsky spolek pro vychovu a opatrovani slepych”. Narodni listy 49(80): 13. Nagarajan, K. 2011. “The Code of Hammurabi: An Economic Interpretation”. International Journal of Business and Social Science 2(8): 108-117.

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Nickalls, R. W. D., and Nickalls, E. A. 1988. “The First Use of Physostigmine in the Treatment of Atropine Poisoning”. Anaesthesia 43: 776-779. Nuland, S. B. 2000. Lekarstvi v prubehu staleti. Doctors, the Biography of Medicine, translated by Kucera and Spanihelova, 114. Prague: Knizni klub. 114. Patil, P. N. 2012. Discoveries in Pharmacological Sciences. New Jersey: World Scientific. Razeghinejad, M. R., and Spaeth, G. L. 2011. “A History of the Surgical Management of Glaucoma”. Optom Vis Sci. 88(1): E39-47. doi: 10.1097/OPX.0b013e3181fe2226. Roman, F. 1993. “The Invention of Spectacles”. Br J Ophthalmol. 77(9): 568. Ruzickova, E. 2000. Glaukom. Prague, Triton. Singh, K. 2008. “Normal Tension Glaucoma: A Different Disease?” Journal of Current Glaucoma Practice. September-December, 2(3): 1. Sneader, W. 2005. Drug Discovery: A History. John Wiley & Sons. Springer, J. 1920. Domaci lekarka: kniha pouceni a vysvetleni pro zdrave i chore o nejdulezitejsich otazkach zdravotnickych a lekarskych. Prague: J. N. Jindra. Tesluk, G. C., and Spaeth, G. L. 1985. “The Occurrence of Primary Openangle Glaucoma in the Fellow Eye of Patients with Unilateral Anglecleavage Glaucoma”. Ophthalmology 92(7): 904-11. Thombs, J., and de Board, L. 2016. “Counselling Patients with Sudden, Irreversible Sight Loss”. Community Eye Health 29(96): 70. Tsatsos, M., and Broadway, D. 2007. “Controversies in the History of Glaucoma: is it All a Load of Old Greek?” Br J Ophthalmol. 91(11): 1561-2. Unknown author. 1910. Narodni listy. 50(256): 3 Unknown author. 1924. “Valecni slepci pamatce prof. dra Jana Deyla”. 1924. Narodni politika. 42(50): 4. Vasek, E. 1924. “Holthova pistelovita operace zeleneho zakalu”. Casopis lekaru ceskych. 28: 1088. Vytlacil, L. 2015. “The Jan Deyl Conservatory and 105 Years Since the Opening of the Deyl Institute for the Blind”. Czech Music Quarterly 15(4): 18-20. Wiggs, J. L., and Pasquale, L. R. 2017. “Genetics of Glaucoma”. Hum Mol Genet. 26(R1): R21-R27. doi: 10.1093/hmg/ddx184.

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Online sources http://www.sukl.cz/modules/medication/detail.php?kod=0154809 Accessed 2018/12/9. https://kjd.cz/ Accessed 2018/12/9. Kovarova, M. 2006. Farmakoterapie primarniho glaukomu s otevrenym uhlem. Thesis, MUNI, Brno. https://is.muni.cz/th/142994/lf_m/Diplomova_prace.pdf. Zahradnickova, K. 2008. Farmakoterapie glaukomu. Thesis, MUNI, Brno. https://is.muni.cz/th/175921/lf_b/Farmakoterapie_glaukomu.pdf.

Other Family chronicle, digitised in 2018 in Trondheim, NOR. P., H. 2018/6/15. Interview. Prague (recorded by Tereza Kopecka). 

CHAPTER NINE MEDICAL ANTHROPOLOGY IN THE LITERATURE OF THE SOCIAL SCIENCES AND POPULAR PROSE AMID FUTURISTIC FEAR AND ADVANCED ALGORITHMS: HUMAN OBSOLESCENCE OR OPPORTUNITY AFTER ALLIANCE WITH ARTIFICIAL INTELLIGENCE AND THE AUTOMATION ECONOMY? KONRAD GUNESCH

AI and Medical Anthropology in Comparative and Multidisciplinary Literature Analysis Recent scientific and popular literature depicts humanity at a crossroads of an unparalleled threat to its humanistic traditions, or an extraordinary opportunity of technological and computerised development of artificial intelligence (AI) or the automation economy. Both pathways are considered to change peoples’ living environment, but also their physical design, psychological makeup, and process of creation. The key to this paradigm shift in conceptualising human quality and existence is the processing power of algorithms which, improving on mechanical, quantitative and machine levels, however has qualitative implications that will let machines overtake and outperform humans even in characteristics and qualities hitherto considered exclusively human, such as creativity, emotions or social interactions. One shorthand explanation is that algorithms do not need to be human if they manage to be better than humans, that is, outperform humans in their traditional domains. These thoughts have been developed in recent

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historical, political, philosophical, cultural and social science bestsellers such as Yuval Noah Harari’s 21 Lessons for the 21st Century (2018) and Homo Deus (2017), or in popular entertainment and literary fiction in Dan Brown’s novel Origin (2017). This literature of social sciences and popular prose is put in context and compared to recent scholarly writings on artificial intelligence and the automation economy, to analyse whether the predicted developments in machine algorithms and the automation economy signal discomforting human obsolescence, or untapped human opportunities. A comparative focus will be on literature in the fields of medical anthropology and healthcare, to test the analyses and predictions of two types of literature (scientific and popular) for the professional future of human versus automated healthcare providers (such as living and machine doctors). This study is socially relevant as we are all either healthcare providers or healthcare seekers, caretakers or caregivers, doctors or patients – and at times both. While this research humbly acknowledges a lack of adequate health care for (still too) many people in the world and the scientific expertise required to understand advanced artificial intelligence, it limits itself to contributing to the challenge of reconciling technological progress with human welfare, in professional life and human healthcare, from a humanistic point of view, and by examining popular and expert writings with social science and literature methods. This chapter examines writings on three levels: 1) popular prose as the most widely accessible form, such as recent bestsellers addressing the relationship between humans and computers, 2) academic literature on the level of popular science, including social sciences not specialised in medical fields, such as in general anthropology, history, politics and philosophy, and 3) specialised literature on medical anthropology and human healthcare. All the examined writings and authors share concerns about the potential and prospects of artificial intelligence for human welfare and working lives, especially the threat of obsolescence for human healthcare professions. Hence this research is a multidisciplinary and comparative content analysis of literary voices at intersections of the fields of medicine, healthcare, medical anthropology, general anthropology, artificial intelligence, the automation economy, social sciences and philosophy. As some of the fields are themselves relatively recent (such as medical anthropology in relation to both medicine and anthropology), and the quoted literature is also often very recent (such as on the automation economy, or on computer algorithms reflecting the exponential progress in

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information technology), this sometimes leads to stacked quotes and one longer quote from Dan Brown’s bestselling novel Origin, to highlight how the novelty of the topics is addressed and complex scientific content is brought in the public eye. The intersection and selection of scientific and popular literature can be exemplified with very recent articles from the Khaleej Times, the leading national newspaper in the United Arab Emirates, the country that appointed “the world’s first AI minister to develop and execute the country’s national AI strategy” (Mourtada 2019, 20). The paper’s monthly supplement “Tech & Transformation” is dedicated to scientific writing that combines academic insights with popular concern and linguistic accessibility, and even features pithy topical cartoons, such as three humanoid robots dancing in a lab in front of two aghast scientists, one clutching a sign “Future of AI”, the other exasperatedly claiming: “This I was afraid of! The robots are claiming their intelligence is real and ours is artificial!” (Nath 2019, 6). The analysis of the writings will tend to move from general sources to specialised medical ones, such as when general stances on artificial intelligence causing human redundancy are followed with examples of AI replacing human healthcare workers and services. Elsewhere, comparative content analysis will juxtapose voices according to sub-topic, for instance professional redundancy of healthcare providers due to progresses in algorithmic computer power. The cultural focus of medical anthropology provides suitable frameworks for our multidisciplinary investigation of the implications of interactions between humans and machines across literary types, and with a focus on human healthcare. The definitions and self-understandings below support our research as centered on multidisciplinary literature analysis, the professional positions and perspectives of healthcare provision and providers, as well as socio-economic elements of artificial intelligence and the automation economy: Anthropologists have always been interested in health. This interest has recently been systematized and synthesized into the area of specialization called ‘medical anthropology’ (Sobo 2004, 10). Medical anthropology has been an eclectic field with roots in many disciplines and methodologies [that] thrives in interdisciplinary stimulation (McElroy and Townsend 2018, xv). The extremely wide variety of topics included within medical anthropology […] is based on the broad, holistic approach that anthropology takes to the study of human biology and cultures. […] Most

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Chapter Nine medical anthropologists, like most anthropologists in general, concentrate on the cultural end of the field (Brown and Closser 2016, 9). Medical anthropology […] provides a point of connection for […] the integration of biological and cultural views of humankind. [It] has already made significant theoretical and empirical contributions to our understanding of the embeddedness of medical knowledge and practice, the dynamics of the healer’s role, the impact of general political and economic forces on the health of individuals and communities, and […] political and economic arrangements (Joralemon 2017, ix). Medical anthropology provides a complex analytic take on the relationships of social structure and context on health […] including insights about economic precarity, powerlessness, workplace exploitation, inequality […] to locate medical anthropology within the larger social science literature (Manderson, Cartwright and Hardon 2016, 6-10).

Popular Literature as a Panopticon of Prognoses on AI-human Conviviality To start with literature that represents popular writings in this research, Dan Brown’s 2017 novel Origin combines the genre of global bestselling entertainment novel with seemingly solidly researched and believably presented scientific background data and scenarios on the conviviality of human and artificial life forms. Brown introduces the “technium” as a new life form between man and machine with enough realism and fluid borders between scientific and popular prose to quote (parts of) an entire scene from his novel, preserving its scientifically dramatic style. Beneath the drama, Brown allows the protagonists to convey a full range of attitudes on the relationship between AI and humans, from technological shock over pessimism to optimism up to a technological utopia. The scene fades in at the worldwide online revelations of the internationally renowned scientist Edmond Kirsch, who has already been publicly murdered, which only serves to heighten public anticipation and viewings. Narrated through the eyes of the novel’s two main remaining protagonists, Harvard Professor Robert Langdon and the Spanish museum curator and arts journalist Ambra Vidal, the world watches the online recording for the first time. Professor Langdon’s voiced reservations make readers both familiar with and critical about the presented technology. The scene’s believability is heightened by references to TED talks, or the protagonists’ backgrounds of world-class researcher, Ivy League professor, and museum curator as well as arts journalist (Brown 2017, 405-412, original emphases):

Medical Anthropology in the Literature of the Social Sciences and Popular Prose amid Futuristic Fear and Advanced Algorithms The screen refreshed to show a graphic timeline of animal evolution beginning some one hundred million years ago. Landon scanned ahead to the 65,000 BC mark, where a thin blue bubble appeared, marking Homo sapiens. Edmond said, ‘in the year 2000, when this graph ends, humans are depicted as the prevailing species on the planet. Nothing even comes close to us […] However, you can see traces of a new bubble appearing…here.’ The graphic zoomed in to show the tiny black shape starting to form above the swollen blue bubble of humanity. ‘A new species has already entered the picture,’ Edmond said. The diagram expanded until it reached the current date, and Langdon felt his chest tighten. The black bubble had expanded enormously over the past two decades. Now it claimed more than a quarter of the screen, jostling with Homo sapiens for influence and dominance. ‘What is that?!’ Ambra exclaimed in a worried half whisper. The diagram expanded again, now displaying the timeline up until 2050. Langdon jumped to his feet, staring in disbelief. ‘My God,’ Ambra whispered, covering her mouth in horror. The diagram clearly showed the menacing black bubble expanding at a staggering rate, and then, by the year 2050, entirely swallowing up the light blue bubble of humanity. ‘I’m sorry to have to show you this,’ Edmond said, ‘but in every model I ran, the same thing happened. The human species evolved to our current point in history, and then, very abruptly, a new species materialized, and erased us from the earth. […] This new species does not entirely erase us. More accurately…it absorbs us.’ […] Awestruck, Langdon watched as Edmond delivered the news to the world, describing an emergent kingdom that Langdon had recently heard about in a TED talk by digital-culture writer Kevin Kelly. Prophesied by some of the earliest science-fiction writers, this new kingdom of life came with a twist. It was a kingdom of nonliving species. It was called: Technium. ‘As you can see, the black bubble of technology, as it consumes the human bubble, assumes a different hue – a shade of purple – as if the two colors have blended together evenly. […] If you don’t believe that humans and technology will fuse,’ Edmond said, ‘take a look around you. Human beings are evolving into something different,’ he declared. ‘We are becoming a hybrid species – a fusion of biology and technology. The same tools that today live outside our bodies – smartphones, hearing aids, reading glasses, most pharmaceuticals – in fifty years will be incorporated into our bodies to such an extent that we will no longer be able to consider ourselves Homo sapiens.’ With a sudden outpouring of hope and optimism, the great futurist launched into a dazzling description of tomorrow, a vision of a future unlike any Langdon had ever dared imagine. Edmond persuasively described a future where technology had become so inexpensive and ubiquitous that it erased the gap between the haves and the have-nots. A future where environmental technologies provided billions of people with

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Chapter Nine drinking water, nutritious food, and access to clean energy. A future where diseases like Edmond’s cancer were eradicated, thanks to genomic medicine. A future where the awesome power of the Internet was finally harnessed for education, even in the most remote corners of the world. A future where assembly-line robotics would free workers from mindnumbing jobs so they could pursue more rewarding fields that would open up in areas not yet imagined. And, above all, a future in which breakthrough technologies began creating such an abundance of humankind’s critical resources that warring over them would no longer be necessary.

Automation Economy’s Work Delegation as an Economic Paradigm Shift and Labour Blessing Taking up the last part of Brown’s words on “breakthrough technologies creating such an abundance of humankind’s critical resources that warring over them would no longer be necessary”, we now look at specialised literature on the automation economy that links it firstly with artificial intelligence, social robotics and nanotechnology, and secondly with the paradigm shift of abundance or post-scarcity. Both aspects will then be related to human healthcare. Convinced that “there is no economic law that producing a good or service must require human labor”, this literature argues that “technology has supplemented or replaced non-elective human labor” (Swan 2017, 27), so that “the automation economy is concerned not just with human survival, but an improved quality of life such that humans can thrive” (Swan 2016, 905). This could even engender individual and social shifts in mindsets from “exclusively human agents to multiple forms of intelligent and emotional agents comprising society” (Swan 2016, 908). Correspondingly, these writers predict “an automation economy that focuses on reduced requirements for human labor […] that targets improved quality of life […] since social robotics implies a much closer connection between humans and technology than other platforms” (Swan 2016, 903). Linking human labour and automation, benefits are seen in “social robotics connecting with both the mechanical labor-saving and the emotional side of human needs […] to facilitate shifts to […] the postlabor automation economy and improved human quality of life” (Swan 2016, 907). The arguably most advanced form of automation, namely nanotechnology, is set to accomplish highly specialised work, but remarkably reverberates with Brown’s words (in Professor Landon’s mind) of abundance: “Advances in nanotechnology [include] self-

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replicating automated mining of asteroids, energy from nuclear fusion or solar-powered satellites, and products from personal nanofactories or fabrication laboratories automated through artificial intelligence […] to imagine economies of abundance” (Jennings 2015, 6). Similarly, “scientists…emphasize the benefits of nanotechnology with an abundance of raw material and self-replicating technologies” (Peters 2009, 11). The same literature explicitly calls for a new understanding of economics, namely “abundance economics” (Swan 2016, 907), “economics of abundance” (Jennings 2015, 6; Shi 2018, 432) “postscarcity economics” (Pressman, 2011, 3); or generally “post-scarcity” (Peters, 2009, 11). In economics research, this is considered a genuine paradigm shift (Saunders 2015, 22-23; Swan 2017, 25 and 2016, 905; Weller 2011, 85; Yamash’ta, et al. 2018, 4-5). Finally, recent writings express optimism about artificial intelligence replacing human labour within an automation economy across borders and industries: “Why not [use] AI personal robots, creating a digital utopia that everyone can enjoy? [An] AI-drive economy would not only eliminate stress and drudgery and produce an abundance of everything we want today, but would also supply a bounty of wonderful products and services” (Tegmark 2017, 119). It seems that from these more sociologically and economically oriented perspectives on human labour, living and working with AI are mostly a matter of positively and responsibly assumed choice resulting in still largely uncharted opportunities. By contrast, the literary positions that follow harbour a much more pessimistic, sometimes even dystopian outlook on man-machine relationships in professional arenas, especially human healthcare.

AI Diagnosis Competence as a Healthcare Paradigm Shift and Redundancy Implication Specialised literature defines artificial intelligence as follows, outlining its applications for human healthcare, and integrating AI into both healthcare and daily life. Importantly, these writings explicitly consider these practices to be a paradigm shift in human health care, thereby restating the core concern of this research regarding human redundancy: Artificial Intelligence (AI) is the field of science concerned with the study and design of intelligent machines. […] Computing methods for learning, understanding, and reasoning can assist healthcare professionals with clinical decision-making, testing, diagnostics, and care management. AI

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Chapter Nine technologies and techniques can advance self-care tools to improve the lives of people, such as interactive mobile health applications (apps) that learn the patterns and preferences of users. AI is improving public health by assisting with the detection of health risks and information interventions. Another example is the use of artificially intelligent virtual humans that can interact with virtual care seekers and provide treatment recommendations. (Luxton 2016, 1-2) Populations are increasingly inclined to integrate Artificial Intelligence (AI) into their daily lives. Although considered as science fiction a few years ago, the AI and its technological advances are already in the process of upsetting whole sections of society, notably [in the] healthcare domain. Indeed, the use of artificial intelligence and new technologies in healthcare systems improves the quality of services and allows better coordination of care (Bouchemal 2019, xiv). AI is bringing about a paradigm shift in behavioral and mental health care. No longer will knowledge and skills of the medical profession be limited to the physician, psychologist, counselor, social worker or other professionals. (Luxton 2016, 20)

Some recent newspaper articles and popular science publications detail how technological progress in AI has already dramatically increased popular access to medical diagnoses, exemplified with Google services predicting concrete but widespread ailments such as the flu. The implication is that healthcare services with such widespread popular access to diagnosis facilities would reduce the need for individually specialised services and personally competent providers: Improved image-recognition has worked wonders in some fields of medicine. For example, Google has developed a system for grading prostate cancer that does it more accurately than US pathologists, and a Stanford team has achieved similar success with skin cancer. Where lots of data exist and precision is valued, AI can help humans make better decisions, even though […] humans […] are better able to correct for their biases. […] If in previous years some AI scholars grumbled that the hype might impede progress because people would become disappointed in the unfulfilled promise of a shiny toy, attention to AI has become too sustained and the financial and intellectual resources thrown at it too enormous for that to happen. Now, competing in AI is a matter of prestige for major nations. (Bershidsky 2018, 9) In 2008 Google […] launched Google Flu Trends, that tracks flu outbreaks by monitoring Google searches […] capable of ringing the flu alarm bells ten days before traditional health services. The Google Baseline Study […]

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intends to build a mammoth database on human health, establishing the ‘perfect health’ profile. Identifying even the smallest deviations from the baseline will hopefully make it possible to alert people to burgeoning health problems such as cancer when they can be nipped in the bud. […] If we give Google and its competitors free access to our biometric devices, to our DNA sans and to our medical records, we will get an all-knowing medical health service, that will not only fight epidemics, but will also shield us from cancer, heart attacks and Alzheimer’s. (Harari 2017, 391392)

In logical furtherance, specialised literature at the interface of healthcare and artificial intelligence raises the concern of human redundancy. It does however not take a decisive stance; this is one of the motivations for the current research: It is difficult to assess what impact AI may have on the job market for healthcare professionals. The advent of many technologies applied to health care, such as the Internet (e.g., eHealth) and mobile devices (e.g., mHealth), has been creating economic opportunities for mental healthcare professionals, rather than eliminating their jobs. Mental healthcare professionals can benefit from involvement in businesses that develop these technologies or through the expansion of their practices via use of these technologies. What may be the most worrisome thought for healthcare professionals, however, is whether continued technological advances will make it possible to build and deploy intelligent machine systems that equal or exceed the social and intellectual capabilities of human care providers. (Luxton 2016, 17-18)

In search of more decisive literary positions on the question of human redundancy in human healthcare, we now look at the second type of literature: academic writings in popular science – encompassing several social sciences, not specialised in any medical fields, but instead in general anthropology, social sciences, and world history. One presently most prolific and prominent author is the historian and philosopher Yuval Noah Harari, whose bestselling book Sapiens: A Brief History of Humankind (2015) caught worldwide attention in both academic and popular science circles. His two most recent books, 21 Lessons for the 21st Century (2018) and Homo Deus: A Brief History of Tomorrow (2017) predict the physical redundancy of human healthcare professionals, especially medical doctors and caregivers, due to increasing algorithmic computer power and artificial intelligence. More widely, Harari states that no human systems or professional capacities constitute a match for a computerised, globally connected information processing power:

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Chapter Nine Since humans are individuals, it is difficult to connect them to one another and to make sure that they are all up to date. In contrast, computers aren’t individuals, and it is easy to integrate them into a single flexible network. […] When considering automation it is therefore wrong to compare the abilities of […] a single human doctor to that of a single AI doctor. Rather, we should compare the abilities of a collection of human individuals to the abilities of an integrated network. […] If the World Health Organization identifies a new disease, or if a laboratory produces a new medicine, it is almost impossible to update all the human doctors in the world about these developments. In contrast, even if you have 10 billion AI doctors in the world – you can still update all of them within a split second, and they can all communicate to each other their feedback on the new disease or medicine. These personal advantages of connectivity and updateability are so huge that at least in some lines of work it might make sense to replace all humans with computers, even if individually some humans still do a better job than the machines. (Harari 2018, 22-23)

For medical and healthcare professions, Harari details how individual doctors would stand little chance against algorithmic networks in either diagnostic depth or quality, due to sheer informational quantity and connectivity: My physician has only a few minutes [for] a few questions and perhaps a quick medical examination [and] then cross-references this meagre information with my medical history, and with the vast world of human maladies. Alas, not even the most diligent doctor can remember all my previous ailments and check-ups [or] be familiar with every illness and drug, or read every new article published in every medical journal. To top it all, the doctor is sometimes tired or hungry or perhaps even sick, which affects her judgement. No wonder that doctors sometimes err in their diagnoses or recommend a less-than-optimal treatment. […] In diagnosing diseases, an AI […] has enormous potential advantages over human doctors. Firstly, an AI can hold in its databanks information about every known illness and medicine in history. It can then update these databanks daily, not only with the findings of new researches, but also with medical statistics gathered from every linked-in clinic and hospital in the world. Secondly, [the AI] will be intimately familiar not only with my entire genome and my day-to-day medical history, but also with the genomes and medical histories of my parents, siblings, cousins, neighbours and friends. Thirdly, [the AI] will never be tired, hungry or sick, and will have all the time in the world for me. […] That is good news for most patients. […] But if you enter medical school today in the expectation of still being a family doctor in twenty years, maybe you should think again. (Harari 2017, 366-367)

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This position is reiterated by specialised medical literature at the nexus of healthcare and artificial intelligence. Outlining “benefits of AI for behavioral and mental healthcare”, it highlights machines’ immunity to human routine fallacies and shortcomings in strikingly similar terms and examples: Intelligent machines have several advantages over human healthcare professionals [namely to] help with highly complex tasks and do so with greater efficiency, accuracy, and reliability than humans. […] Machines that provide care services are not susceptible to fatigue, boredom, burnout, or forgetfulness [and] immune to personal biases that human therapists may have. Some patients may prefer encounters with intelligent machines, such as virtual humans rather than human therapists for this reason, and care seekers may experience less anxiety when discussing intimate, private issues with a machine than they would with another person. This notion is supported by initial evidence indicating that some people may be more comfortable disclosing information to virtual humans during clinical interviews and prefer to interact with virtual humans than with medical staff […]. One reason for this preference is that virtual humans are able to spend more time with patients, are always friendly, and do not make users feel rushed or judged. (Luxton 2016, 15)

Specifically regarding “integration and customization of care”, this literature deepens Harari’s critique of human care (no matter how medically qualified and morally well-intentioned) with examples of automated processes and devices outperforming humans even in areas considered traditional, typical and thus unique human domains: Intelligent care-providing machines have the potential to greatly improve health outcomes […] by customizing their care. These systems could be programmed with the knowledge and skills of diverse evidence-based approaches and then deliver the most appropriate therapy or integrate different approaches based on a patient’s diagnostic profile, preferences, or treatment progress. […] Machines may also be capable of sensitivity and adaptation to specific aspects of a patient’s culture such as race/ethnicity or socioeconomic status. For example, a virtual human psychologist could change its mannerisms (e.g., eye contact), speech dialect, use of colloquialisms, and other characteristics to match a given cultural group and thus develop and enhance rapport with a patient and improve overall communication. By integrating data from other intelligent services such as environmental sensors, wearables, and biofeedback devices, intelligent systems can further customize services. […] These capabilities will only improve as technology continues to become smaller in size, more integrated with other technologies, and more ubiquitous in everyday life. (Luxton 2016, 16)

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With popular and specialised scientific literature agreeing on certain categories of professional redundancies, even more troubling from the viewpoint of human professionals and caregivers, Harari stresses that such redundancies are already at the point of afflicting not only generalists as one might intuitively expect, but even more specialists: It might prove easier to replace doctors specialising in relatively narrow fields such as cancer diagnosis. In recent experiments a computer correctly diagnosed 90 per cent of lung cancer cases presented to it, while human doctors had a success rate of only 50 per cent. […] CT scans and mammography exams are routinely checked by specialised algorithms, which provide doctors with a second opinion, and sometimes detect tumors that the doctors missed. (Harari 2017, 268)

For such redundancies and thus displacements of human doctors with AI doctors, Harari differentiates that in the short-term, AI might be prohibitively expensive, while in the long-term, even huge initial investments can be recuperated: Technical problems still prevent [AI] from displacing most doctors tomorrow morning. Yet these technical problems […] need only be solved once. The training of a human doctor is a complicated and expensive process that lasts years. […] After a decade or so of studies and internships, all you get is one doctor. If you want two doctors, you have to repeat the entire process from scratch. In contrast, if and when you solve the technical problems hampering Watson, you will get not one, but an infinite number of doctors, available 24/7 in every corner of the world. So even if it costs $100 billion to make it work, in the long run it would be much cheaper than training human doctors. (Harari 2017, 368)

This economies-of-scale-argument (that even huge investments in innovative technologies are recuperated profitably once large-scale applications result in lower per-item costs) is explicitly echoed in the specialised literature: Because intelligent machine care providers can be easily replicated (especially software-based ones), they will bring an economy of scale to care delivery. The increased accessibility and lower cost of intelligent machines that provide care might provide opportunities for longer-term treatments that are currently restricted by managed-care costs. […] Thus, patients will have the opportunity to participate in longer-term therapies and also receive periodic check-ups at greatly reduced costs to healthcare providers. (Luxton 2016, 17)

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Machines’ Medical Superiority Contributing to Comprehensive Healthcare Democratization Harari then addresses the objection that those interconnected units of artificial intelligence, however profitable, lack some of the qualities that are considered uniquely human, such as creativity, besides harbouring potential disasters, such as system-wide programming or processing mistakes. He again ends up with the argument of human redundancy: You might object that by switching from individual humans to a computer network we will lose the advantages of individuality. For example, if one human doctor makes a wrong judgement, he does not kill all the patients in the world, and he does not block the development of all new medications. In contrast, if all doctors are really just a single system, and that system makes a mistake, the results might be catastrophic (Harari 2018, 23). Of course not all human doctors will disappear. Tasks that require a greater level of creativity than run-of-the-mill diagnosis will remain in human hands for the foreseeable future. […] However, just as armies no longer need millions of GIs, so future healthcare services will not need millions of GPs. (Harari 2017, 268)

Harari even turns that objection around, namely that it is precisely the lack of human individuality that lets AI doctors outperform humans; at least on average, in the long run, and with an increasing number of patient cases, due to their connected and accumulated algorithmic power, and because of their lack of human or emotional fallibility: An integrated computer system can maximise the advantages of connectivity without losing the benefits of individuality. You can run many alternative algorithms on the same network, so that a patient in a remote jungle village can access through her smartphone not just a single authoritative doctor, but […] a hundred different AI doctors, whose relative performance is constantly being compared (Harari 2018, 23). Some people argue that even if an algorithm could outperform doctors and pharmacists in the technical aspects of their professions, it could never replace their human touch. If your CT indicates you have cancer, would you prefer to receive the news from a cold machine or from a human doctor attentive to your emotional state? Well, how about receiving the news from an attentive machine that tailors its words to your feelings and personality type? […] A human doctor recognises your emotional state by analysing external signals such as your facial expressions and your tone of voice. Watson could […] analyse such external signals more accurately [by] monitoring your blood pressure, brain activities and countless other

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Specifically, Harari argues, computer and AI algorithms producing Big Data would ultimately be able to analyse, thus understand, and therefore advise on human bodies, health and even needs much better than humans themselves. The key is in-built biometric sensors that feed constant streams of live data to the installed computer systems. The definition of big data serves to hammer home Harari’s point of no-contest between human and machine information processing: Big data is characterized by the ‘three V’s’ of volume (large quantities) […], variety (heterogeneity) […], and velocity (fast access) [and] in medicine […] from many sources: electronic health records, medical literature, clinical trials, insurance claims data, pharmacy records, and even information entered by patients into their smartphones or recorded on fitness trackers (Price 2017, 10, original emphases). Big Data algorithms informed by a constant stream of biometric data could monitor our health 24/7. They could detect the very beginnings of influenza, cancer or Alzheimer’s disease, long before we feel anything is wrong with us. They could then recommend appropriate treatments, diets and daily regimens, custom-built for our unique physique, DNA and personality. […] The key invention is the biometric sensor, which people can wear on or inside their bodies, and which converts biological processes into electronic information that computers can store and analyze [if] given enough biometric data and enough computing power. (Harari 2018, 48-50)

Harari’s conclusion at the intersection of healthcare and work is that this non-human capacity is superior and thus advantageous for humanity, and ultimately leads to the complete democratization of human healthcare: AI doctors could provide far better and cheaper healthcare for billions of people. […] Thanks to learning algorithms and biometric sensors, a poor villager in an underdeveloped country might come to enjoy far better healthcare via her smartphone than the richest person in the world gets today from the most advanced urban hospital. […] In Toronto, Tokyo, Tehran or Tel Aviv, you will be taken to similar-looking hospitals, where you will meet doctors in white coats who learned the same scientific theories in the same medical colleges […] follow identical protocols and use identical tests to reach very similar diagnoses [and] then dispense the same medicines produced by the same international drug companies [and] hold much the same views about the human body and human diseases. (Harari 2018, 23, 106-107)

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The specialised literature on AI applications in human healthcare shares Harari’s view of “improved self-care and access to care” which are more widely and equally spread geographically and culturally: The use of intelligent care-providing machines also extends the benefits of telehealth services by providing services to care seekers in remote geographical areas and provides access to specialty care services that may not be available in the patient’s area […] accessible anywhere and at any time on mobile devices to […] conduct question-and-answer assessments, provide self-care counseling, and deliver therapeutic interventions. […] Moreover, intelligent mobile and wearable devices can increase the amount of data that are available to users and can provide them with more information to assess health and monitor progress toward individualized health goals. (Luxton 2016, 15-16)

Ultimately, Harari holds that workplace automation in healthcare is not just advantageous, but should rationally be pursued for the sake of humanity: For the then-redundant doctors, Harari however offers positive perspectives that would only require but also allow them to qualify further, and therefore be also more in demand and remunerated: Hence it would be madness to block automation in […] healthcare just in order to protect human jobs. After all, what we ultimately ought to protect is humans – not jobs. Redundant […] doctors will just have to find something else to do. […] The loss of many traditional jobs in […] healthcare will partly be offset by the creation of new human jobs. GPs who focus on diagnosing known diseases and administering familiar treatments will probably be replaced by AI doctors. But precisely because of that, there will be much more money to pay human doctors and lab assistants to do groundbreaking research and develop new medicines or surgical procedures. AI might help create new human jobs in another way. Instead of humans competing with AI, they could focus on servicing and leveraging AI. (Harari 2018, 24, 28-29)

Healthcare’s “Super clinician” and Anthropology’s Ethical Concerns Specialised literature on the intersection between AI and healthcare has put forward a concept that would fulfil both medical and popular literature’s demands and dreams, namely the “super clinician” (Luxton 2016): it would for instance eliminate many of the shortcomings and fill many of the gaps that Harari and others have diagnosed in human healthcare services and caregivers, and embody the ideal caregiver

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according to both scientific and popular literature. Yet specialised medical literature is also careful to highlight the pervading conceptual and practical limitations. These point to future research areas, as mentioned below in the conclusions and recommendations: The super clinician […] is a proposed intelligent machine system that would integrate […] technologies [such as] facial recognition technology to verify the identity of patients and also advanced sensory technologies to observe and analyze nonverbal behavior such as facial expressions, eye blinking, vocal characteristics, and other patterns of behavior. Computer sensing technology could also access internal states that are not detectable by the human eye, such as by observing changes in body temperature with infrared cameras or blood flow in the face with high-resolution digital video processing techniques. The system could be capable of accessing and analyzing all data available about patients from electronic medical records, previous testing results, and real-time assessments collected via mobile health devices. [It could also] learn every therapeutic approach, and […] apply the best treatment or intervention. Human interaction […] could be accomplished via a robot, a virtual human, or perhaps a voice-only entity with ambient sensors strategically placed within an office. […] However, there are technological barriers that limit our ability to build intelligent machines as […] the imagined super clinician. Such a system would require reliable integration of the component technologies and the ability to process complex and ambiguous meaning from conversations in order to function autonomously. […] Another concern […] is […] the loss of something inherent to the helping professions: human-to-human expression of empathy, care, and compassion [and] basic human physical presence and contact, such as shaking hands before and after a session with a patient, placing a hand on the shoulder of a person who is overcome with grief, or handing a patient a tissue to dry their tears. Virtual humans and robots are being improved in their capability to recognize, respond to and express emotions (and in the case of a robot to provide touch). Whether or not simulated acts of empathy and caring kindness are experienced as analogous to the real thing, or whether it matters if they are, are questions that will require further study as we continue to develop intelligent careproviding machines. (Luxton 2016, 18-19, original emphases)

One can probably agree that humans creating and designing artificial intelligence retain control and responsibility for technological processes, individual applications and social outcomes. As Belle cites Steve Jobs in a 1994 interview: Technology is nothing. What’s important is that you have faith in people, that they’re basically good and smart, and if you give them tools, they’ll do wonderful things with them. It’s not the tools that you have faith in – tools

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are just tools. They work or they don’t work. It’s people that you have faith in. (Belle 2018, 5)

However, Harari is aware of the de-individualising potential in delegating knowledge about ourselves and therefore decision-making power to artificial intelligence based solely on algorithmic parameters: As authority shifts from humans to algorithms, we may no longer see the world as the playground of autonomous individuals struggling to make the right choices. […] My illusion of free will is likely to disintegrate as […] the algorithms […] monitor all your steps, all your breaths, all your heartbeats. […] And once these algorithms know you better than you know yourself, they could control and manipulate you, and you won’t be able to do much about it. […] In the end, it’s a simple empirical matter: if the algorithms indeed understand what’s happening within you better than you understand it, authority will shift to them. Of course, you might be perfectly happy ceding all authority to the algorithms and trusting them to decide things for you. […] If, however, you want to retain some control of your personal existence […] you have to run faster than the algorithms […] and get to know yourself before they do. (Harari 2018, 48, 56, 268)

Some recent popular science voices place AI technology within even broader ethical contexts, such as economic utility or monitoring people’s lives in all aspects beyond health care, from shopping decisions to the most private and incisive matters. Like Harari, they see professional opportunities as equalling or even positively outweighing those job losses caused by AI technology. They therefore raise demands for socially reflected and agreed-upon ethical frameworks: How far can we push the boundaries on AI? […] It is important to develop a rules-based model for the system to operate in. This calls for regulation (Tesorero 2018, 4). Algorithms will force us to recognise how the outcomes of past social and political conflicts have been perpetuated into the present through our use of data. […] A broader debate about the ethics of AI has begun to emerge […] beyond the use of algorithmic decisionmaking in corporate and political governance [that] strikes at the ethical foundations of our societies. While we certainly need to debate […] maximizing ‘utility’ through AI, we also need to engage in self-reflection. Algorithms are posing fundamental questions about how we have organised social, political, and economic relations to date. We now must decide if we really want to encode current social arrangements into the decision-making structures of the future. Given the political fracturing currently occurring around the world, this seems like a good moment to write a new script. (Coyle 2018, 9)

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Conclusions and Recommendations The literature voices of popular science, and especially one of such high popular appeal as Harari, seem to consider artificial intelligence based on advanced algorithms and used on a wide social scale mostly as a black-and-white future scenario with winners and losers in the form of a zero-sum game. Humans seem to be largely on the losing, and machines on the winning side. The only exception and allowance are made for those humans, for instance doctors and healthcare givers, who actively seek to improve their lot and their qualifications by serving AI to serve their patients. Even writers successfully straddling the scientific and popular realms, and highly qualified academically, such as Harari, seem to succumb to technological pessimism. This research is not the place to speculate about underlying motivations such as books about the future (as news) selling better if dressed in doubts and cast in criticism. Yet several points seem striking: first, this technological pessimism seems reflected in some forms of popular entertainment, as in movies about machines taking control of the world and its inhabitants. For instance, the 2004 Will Smith action movie I, Robot, paints a dystopian picture of man-machine relationships with the one-sided superiority of machine domination and human depression. The movie’s only human able to stand up to power-hungry machines is himself a hybrid of man and machine, having been given replacement limbs after a near-fatal car accident and now endowed with the physical assets (and hard enough body parts) to fight tyrannising robots at every turn and corner. Second, other forms of popular entertainment, such as Dan Brown’s bestselling novels, after having (dramatically effectively) taken the reader through rollercoaster rides of technological end-of-days scenarios, tend to end on optimistic outlooks such as in the earlier quoted passage where Professor Langdon comes to terms and makes peace with the “technium”. Third, the specialised medical, anthropological and healthcare literature seems, in comparison, much more at ease with artificial intelligence, automated potential and algorithmic power, predicting manmachine interaction to be ever more efficient on the part of the latter and beneficial for the former. This is suggestively reflected in the tell-tale phrase of the protagonist evolving from machine to man, named “One” (played by Robin Williams) in the 1999 science-fiction comedy drama Bicentennial Man: “One is happy to serve”. Yet it is the socio-economic literature on the automation economy that seems conceptually and practically most comfortable with all kinds of notions and practices of artificial intelligence, from social robotics to

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nanotechnology, all advocating the facilitation of human labour. A conceptual and practical space deserving to be watched in the future is the declared paradigm shift towards an abundance or post-scarcity economy: if an appropriate management of natural, human and technological resources could indeed lead to a more fulfilled human existence, then the coexistence of man and machine might be considered as one of its aspects, requiring no more – but also no less – than an insightful, sensitive and wise philosophy for the automation economy and algorithms to be used in the service of humans. The specialised literature at the interface of healthcare and artificial intelligence has already suggested several areas of future research, especially regarding interactions between humans and machines, or persons’ reactions to forms of medical caregiving that are delivered as automated in form yet perceived as efficient in result. It might be advisable to take a page out of the book of those literature voices that postulate technological progress and service diversification as desirable to pursue, especially in healthcare services, and for the benefit of humans. Their relaxed and upbeat attitude towards artificial intelligence and the automation economy might still need to be tempered with warnings about ethical implications or loss of human autonomy over personal power and social space. Yet even those sceptical of speedy technological advances have so far not found indications that artificial intelligence still presupposes human intelligence. If the latter continues (or is ever more) based on universal and timeless human wisdom, epiphanies like the one Harvard professor Robert Langdon experiences in Origin might equally, or at least equitably bless doctors and patients, teachers and students, people and societies. Maybe then, (self-)programming man and machine in positive and optimistic ways to embrace each other could result in technological and human win-win situations and relationships on individual, institutional and international levels.

References Belle, Nithin. 2018. “Seismic Changes in Modern Times: Emerging Technology can be Harnessed and Implemented for its Potential in Broader Domains of Industry, Commerce and Civil Life.” Tech & Transformation: Disruption Inevitable (Khaleej Times Supplement), October 2: 4-5. Bershidsky, Leonid. 2018. “AI Wars are Breaking Out. The Winners Will Rule the World: The US is Emerging as a Leader in Patents but China and Europe are not Far.” Khaleej Times, 30 December: 9.

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Bouchemal, Nardjes. 2019. “Preface.” In Nardjes Bouchemal (ed.), Intelligent Systems for Healthcare Management and Delivery, xiv-xxv. Hershey: Pennsylvania: IGI Global. Brown, Dan. 2017. Origin. New York: Penguin Random House. Brown, Peter J., and Svea Closser. 2016. “To the Student.” In Peter Brown and Svea Closser (eds.), Understanding and Applying Medical Anthropology, 3rd edition, 9-10. London and New York: Routledge. Coyle, Diane. 2018. “AI is Logical and Biased, and that’s a Problem: Machines and Websites that run on Algorithms serve the Purpose of People and Companies that Code them.” Khaleej Times, 18 December: 9. Harari, Yuval Noah. 2018. 21 Lessons for the 21st Century. New York: Jonathan Cape and Penguin Random House. —. 2017. Homo Deus: A Brief History of Tomorrow. New York: Vintage and Penguin Random House. —. 2015. Sapiens: A Brief History of Humankind. New York: Harper Collins. Jennings, Frederick B. 2015. “Abundance and Scarcity.” In Frederick F. Wherry and Juliet B. Schor (eds.), The Sage Encyclopedia of Economics and Society. Los Angeles and London: Sage Publications. Joralemon, Donald. 2017. Exploring Medical Anthropology, 4th edition. Oxon and New York: Routledge. Luxton, David D. 2016. “An Introduction to Artificial Intelligence in Behavioral and Mental Health Care.” In David D. Luxton (ed.), Artificial Intelligence in Behavioral and Mental Health Care, 1-26. Amsterdam, Boston and London: Elsevier. Manderson, Lenore, Elizabeth Cartwright, and Anita Hardon. 2016. “Introduction: Sign Posts.” In Lenore Manderson, Elizabeth Cartwright, and Anita Hardon (eds.), The Routledge Handbook of Medical Anthropology, 2-14. New York and Oxon: Routledge. McElroy, Ann, and Patricia K. Townsend. 2018. In Medical Anthropology in Ecological Perspective, 6th edition. New York and Oxon: Routledge. Mourtada, Rami. 2019. “The AI Gap: Why ME needs to Disrupt Businesses Now.” Khaleej Times, 10 January: 20. Nath, Paresh. 2019. “This I was Afraid of! The Robots are Claiming their Intelligence is Real and Ours is Artificial!” Khaleej Times, 5 January: 6. Peters, Michael A. 2009. “Introduction: Knowledge Goods, the Primacy of Ideas and the Economics of Abundance.” In Michael A. Peters, Simon Marginson, and Peter Murphy (eds.), Creativity and the Global

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Knowledge Economy, 1-22. New York and Oxford: Peter Lang Publications. Pressman, Steven. 2011. “John Kenneth Galbraith and the Post Keynesian Tradition in Economics.” In Steven Pressman (ed.), The Legacy of John Kenneth Galbraith, 1-15. Oxon and New York: Routledge. Price, W. Nicholson. 2017. “Artificial Intelligence in Health Care: Applications and Legal Implications.” The SciTech Lawyer 14 (1): 1013. Saunders, Olivia. 2015. Tomato Economics: Shifting Economics from Scarcity to Abundance. Bloomington: Xlibris. Shi, Juwei. 2018. “Buddhist Economics: A Cultural Alternative.” In Stomu Yamash’ta, Tadashi Yagi, and Stephen Hill (eds.), The Kyoto Manifesto for Global Economics: The Platform of Community, Humanity, and Spirituality, 417-435. Singapore: Springer. Sobo, Elisa J. 2004. “Theoretical and Applied Issues in Cross-cultural and Applied Health Research: Key Concepts and Controversies.” In Carol R. Ember and Melvin Ember (eds.), Encyclopedia of Medical Anthropology: Health and Illness in the World’s Cultures, Volume 1, Topics, 3-11. New York: Springer. Swan, Melanie. 2016. “Philosophy of Social Robotics: Abundance Economics.” In Arvin Agah, John-John Cabibihan, Ayanna. M. Howard, Miguel A. Salichs, and Hongsheng He (eds.), Social Robotics: 8th International Conference, ICSR 2016, Kansas City, MO, USA, November 1-3, 2016, Proceedings, 900-908. New York and Cham: Springer. Swan, Melanie. 2017. “Is Technological Unemployment Real? An Assessment and a Plea for Abundance Economics.” In Kevin LaGrandeur and James J. Hughes (eds.), Surviving the Machine Age: Intelligent Technology and the Transformation of Human Work, 19-34. New York and Cham: Springer. Tegmark, Max. 2017. Life 3.0: Being Human in the Age of Artificial Intelligence. New York and Toronto: Penguin Random House. Tesorero, Angel. 2018. “AI can Tell What You’re Buying Next.” Khaleej Times, 12 December: 4. Weller, Martin. 2011. The Digital Scholar: How Technology is Transforming Scholarly Practice. London and New York: Bloomsbury Academic. Yamash’ta, Stomu, Tadashi Yagi, and Stephen Hill. 2018. “The Path: From the Sacred Harmony of Humanity to a New Economics.” In Stomu Yamash’ta, Tadashi Yagi, and Stephen Hill (eds.), The Kyoto

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Manifesto for Global Economics: The Platform of Community, Humanity, and Spirituality, 3-11. Singapore: Springer.

PART 4 LITERARY PORTRAITS OF MEDICINE

CHAPTER TEN HUNGER DIVINE: RELIGIOUS ELEMENTS AND CULTURAL ASSUMPTIONS ABOUT THE FEMALE BODY IN AMERICAN WOMEN’S NARRATIVES OF ANOREXIA EMMA DOMÍNGUEZ-RUÉ

Introduction In our society, food is not chosen, cooked and eaten on the sole basis of hunger, nutrition or health. In the contemporary Western world, you are what you eat – or rather, in the case of women, what you refuse to eat. In contrast, refusing to eat and therefore being able to control appetite is viewed as a sign of success and moral strength in a woman, as Marya Hornbacher writes: Success, I firmly believed, was the key to my salvation. It would absolve me of the sins of the flesh and the soul, lift me out of the life I hated. ‘Success’ meant a perfect career, perfect relationships, perfect control over my life and myself – all of which depended on a perfect me, which depended in turn on me living inside a perfect body. (Hornbacher 1998, 232)

As Susan Bordo has similarly noted, food refusal, weight loss, commitment to exercise and ability to tolerate bodily pain and exhaustion have become cultural metaphors for women’s self-determination, will, and moral fortitude (Bordo 1993, 68). The woman’s body thus seems to be, today as much as ever, the battlefield for freedom, as anxieties about what and how much to eat substantiate the notion that the female body is a cultural product and an object of observation. As Iris Marion Young contends, “the objectified bodily existence accounts for the self-

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consciousness of the feminine relation to her body and resulting distance she takes from her body” (Young 2005, 44). According to this and other studies (Chernin 1981; Hesse-Bieber 1996; Seid 1989), such cultural representations of the female body have thus contributed to developing a distorted relationship between women and their bodies, as Marya Hornbacher reflects in her painful narrative of her descent into anorexia: “And so I went through the looking-glass, stepped into the netherworld, where up is down and food is greed, where convex mirrors cover the walls, where death is honor and flesh is weak” (Hornbacher 1998, 10). This view seems to be substantiated by figures since, as early as 1995, Margaret Miles recorded that the disparity between the representations of women’s bodies in society and the bodies of actual women was alarmingly increasing. In 1960, the average model in North American advertising weighed 8% less than the average woman; in 1990, the average model weighed 23% less (Miles 1995, 555). More recent studies such as that of Venera Dimulescu (2015) only seem to emphasise this tendency. Medieval scholarship has demonstrated that there have been various moments in history in which women have either refused to eat or have eaten extremely limited amounts of food (Brumberg 2000, 5). However, women in different cultures and in different periods in history have had various reasons for food refusal and have interpreted the signification of food and the female body in different ways. As I will presently argue, there are emotional features related to the phenomenon of fasting – such as denial, control, sacrifice and moral reward – which can be associated to both medieval religious asceticism and cultural assumptions about the female body that are noticeably present in contemporary narratives of anorexia. This chapter intends to identify the religious components in cultural assumptions about the female body, together with their reflection in anorexic behaviour as informed by contemporary American narratives of anorexia. To this purpose I will use three books that I consider representative of the genre: Jillian Medoff’s novel Hunger Point (1997), Marya Hornbacher’s memoir Wasted (1998), and Lynne Ruth Miller’s novel Starving Hearts (2001). This essay is not meant to be a psychological treatise but rather a comment on the extent to which cultural texts can reveal the negative impact of certain cultural values attached to women’s behaviour in our societies, as well as their role in triggering such destructive disorders. Although these three works vary in multiple respects, they share common traits and seize a red-hot topic of present-day Western countries, both presenting painful personal accounts of the disease and interrogating the role of family, environment and social predicaments in the appearance and development of anorexia. My main

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contention here is that the relationship between the ascetic and the aesthetic, albeit inherited from a Christian tradition, is no longer ascribed to the realm of religious asceticism but has become part of contemporary society and – more specifically – of cultural notions ascribed to the female body. As Grace Bowman aptly states, Our society equates success with thinness; we are told that they go hand in hand; a successful woman is one who is shrinking. Flesh and fat are considered to be the anti-thesis of power, control and achievement. Often, a celebrity female’s success is based on an image of persistence, of selfcontrol and of willpower over her body. Could it therefore follow that the anorexic girl who cannot conceive because her periods have stopped, who has reverted out of womanhood, and who represents a sense of closure and isolation, is telling us that she has attained total perfection? (Bowman 2007, 127)

The following section will briefly contextualise anorexia nervosa in order to provide a framework for the literary works analysed. The rest of the chapter will proceed to examine the issues that relate ascetic practices with present-day anorexic behaviour as informed by the three works analysed – namely, the relationship between ascetics and aesthetics, the notion of transgression and punishment, and the anorexic sense of denial and control – while it will analyse the influence of all the former aspects as part of sociocultural predicaments and family dynamics.

Anorexia Nervosa Anorexia nervosa was named and identified as a disease in the Victorian era, as its diagnosis emerged from the specific economic and social conditions of that period. It was first identified as such almost simultaneously by Dr. Ernest Charles Lasègue and Sir William Whitey Gull in 1873, although the American doctor William Stout Chipley had already coined the term sitomania in 1859 to define a disorder that consisted of “a fear of eating”. Although professional literature distinguishes between the adjective “anorexic” and the noun “anorectic”, I will use “anorexic” in both cases for the sake of clarity and simplicity. According to the Medical Dictionary online, anorexia nervosa today is defined as follows: an eating disorder usually occurring in adolescent females, characterized by refusal to maintain a normal minimal body weight, fear of gaining weight or becoming obese, disturbance of body image, undue reliance on body weight or shape for self-evaluation, and amenorrhea. The two

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subtypes include one characterized by dieting and exercise alone and one also characterized by binge eating and purging.

The criteria for diagnosis of anorexia nervosa identified by the American Psychiatric Association are the following: (1) intense fear of becoming obese that does not diminish as weight loss progresses; (2) disturbance of body image, such as claiming to feel fat even when emaciated; (3) refusal to maintain body weight over a minimal normal weight for age and height; (4) no known physical illness that would account for the weight loss; and (5) amenorrhea in postmenarchal females. It is often accompanied by self-induced vomiting or use of laxatives and/or diuretics and extensive exercise. Accompanying physical signs in addition to profound weight loss include hypotension, bradycardia, edema, lanugo, metabolic changes, and endocrine disturbances.

In Fasting Girls, Joan Jacobs Brumberg points to three major theoretical explanations of the causes of anorexia: biomedical, psychological and cultural. The biomedical approach postulates that anorexia is caused by endocrinological and neurological abnormalities, the hypothalamus being the most plausible source of the dysfunction (Brumberg 2000, 27). Apart from the fact that drug treatment has not proved to be effective against the disease, this approach fails to explain why most sufferers of anorexia are young women from the middle and upper classes (Brumberg 2000, 28-29). The psychological model regards anorexia as a pathological response to the adolescent crisis, whereby the adolescent feels unable to cope with the change into adulthood and sexuality. Many patients display traits of an obsessive-compulsive behaviour, such as perfectionism, excessive order and cleanliness, meticulous attention to detail and self-righteousness (Brumberg 2000, 31). Psychology, however, cannot explain why anorexia is largely restricted to women belonging to certain social classes and specific societies (Brumberg 2000, 33). The cultural approach explains anorexia as a response to the imperative of thinness as the most important quality of female beauty (Brumberg 2000, 33). Nonetheless, the bombarding of media with images of skinny bodies and advice on how to lose weight cannot be regarded as the only cause of anorexia, as Peggy Claude-Pierre has observed. Rather than a cause, she views the cult of thinness as “a possible trigger” (Claude-Pierre 1997, 67). In view of these theories, one discerns that anorexia nervosa is a complex mental disorder that cannot be reduced to a single cause: it varies in each individual case and depends on individual biologic conditions,

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psychological characteristics, family and environment (Brumberg 2000, 26). As Hornbacher puts it, Eating disorders are ‘about’: yes, control, and history, philosophy, society, personal strangeness, family fuck-ups, autoerotics, myth, mirrors, love and death and S&M, magazines and religion, the individual’s blind-folded stumble-walk through an ever-stranger world … It is a response, albeit a twisted one, to a culture, a family, a self. (Hornbacher 1998, 4-5)

As literature scholars and cultural critics, however, it is our concern to point at the elements in our cultural value system that might contribute to such a destructive tendency. In The Hungry Self, Kim Chernin has remarked upon the afore-mentioned correlation between weight and women’s self-esteem, by which thinness is associated with attractiveness, success and happiness (Chernin 1985). Indeed, women have always been praised for their beauty more than for any other quality they might possess: it is therefore not strange that our fitness-maniac and fat-phobic society drives women to constant dieting. As Grace Bowman contends, That is the thing about anorexia; it uncomfortably reflects back society’s ideals gone wrong, the misshapen view that perfection and happiness are obtainable through the body. … the job of trying to imagine myself with a bigger, so-called healthier body, which everyone kept asking me to do, was made more difficult by the presence of the perfect, glossy images of the ideal body which surrounded me. Even though they were thin like me, they were thick with gloss and shine and health. So how could I be so wrong? (Bowman 2007, 125-126)

Margaret Miles among others has noticed that there are startling continuities between contemporary eating disorders and food practices by medieval women (Miles 1995, 552-553). The most frequent similarities are to me the following: (1) an aesthetic component that links extreme thinness with moral virtue and success; (2) the perception of eating as transgression and the consequent need for its atonement; and (3) a sense of self-control derived from self-denial, with the conviction that self-sacrifice is rewarding. I will then discuss the influence of all the former aspects as they operate in the framework of family environment and/or sociocultural assumptions about gender roles. I will examine these aspects as they appear in the three novels and attempt to determine the degree in which these religious notions are present in modern cultural assumptions about the female body and how they concur with the food practices of contemporary anorexics as described by the texts.

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Ascetics and Aesthetics: Divine Fasting Many medievalists have noticed that a great number of female saints became so through spending long periods of time fasting, while considerably fewer male saints are known for this practice. For instance, Rudolph Bell and Donald Weinstein have claimed that women were only 18% of those canonised as saints, but they were 30% of those whose extreme austerity was central in their lives, and approximately 50% of those whose reputation for sanctity was based on fasting (Weinstein and Bell 1982). In another work, Bell similarly records that half of the 42 Italian women who became saints in the thirteenth century followed the same behaviour pattern, which he labels “holy anorexia” (Bell 1985). During the medieval period, and especially between 1200 and 1500, food refusal and prolonged fasting were considered a female miracle: ascetic food practices provided medieval holy women with a metaphor to express the religious values of suffering and sacrifice and with a way to reach a status in the religious hierarchy that would otherwise be impossible to attain for a woman (Brumberg 2000, 47). Hilde Bruch’s quote from an anorexic patient bears a disturbing resemblance to medieval women mystics: “my body became the visual symbol of pure ascetic and aesthetic, of being sort of untouchable in terms of criticism” (Bruch 1978, 17). It bears a shocking similarity with Grace Bowman’s account: “I draw these lines around me and shut everything out. I shut you out. I close up my mouth and I am whole. Impenetrable” (Bowman 2007, 137). These quotes seem to replicate the religious notion that fasting purifies the body, therefore withdrawing the spirit from worldly concerns and elevating the soul, as Hornbacher’s unsettling words indicate: “The dark place that my mind was fast becoming blends, in my memory, with the dark womb of church: the chant, the fugue of prayer, the strange erotic energy that carving a very small cross into my thigh with a nail had brought” (Hornbacher 1998, 59). Moreover, it points to an “aesthetics of thinness” that equates the emaciated body with a high moral standing. We can therefore distinguish an aesthetic component that links both groups of women, namely the Platonic dualism of body and mind and the resulting equation of slenderness with moral virtue. Caroline Banks contends that although medieval holy women were aware of their reasons for self-starvation while modern anorexics may not necessarily have been, anorexics also give meaning to her thinness and use their culture to do so (Banks 1996, 108), as Hornbacher’s reflections in Wasted evidence: I hear this in schools all over the country, in cafés and restaurants, in bars, on the internet, for Pete’s sake, on buses, on sidewalks … Not eating, in

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Banks interestingly focuses on anorexic women's sense of moral superiority and their praise of self-control against self-indulgence. As Bowman shows, their excessive preoccupation for order, perfection, and control reflects traits of an obsessive-compulsive personality that Banks links with moral and ethical values: “Nothing gets in her way. Success is everything. She likes to arrange things, and people. … She is acknowledged. She has achieved. It must continue” (Bowman 2007, 11). As Banks contends, their repetitive and obsessive behaviour as regards food practices (like eating only at night or only when no one can see them, cutting all food in tiny pieces, carefully and obsessively counting the calories of everything they eat, etc.) can be viewed as a form of ritual and would thus establish an analogy between both groups of women (Banks 1996, 121, 127). The aesthetics of thinness, however, obviously have completely different connotations for religious ascetics and anorexic sufferers. Contemporary anorexics value extreme thinness to mirror the image of glamour and success that the media convey; medieval women mystics, however, gave their slenderness a religious significance by identifying their bodies with the sufferings of Christ. In Holy Feast and Holy Fast, Caroline Bynum seems to corroborate this idea by questioning the notion that medieval asceticism was an attempt to escape from the body; rather, it was an identification with both the suffering and nurturing flesh of Christ. Suffering is to medieval women a way of serving God: by starving, they joined Christ’s sufferings on the cross, while they also redeemed the sins of the world or the pain of others. According to Bynum, “fasting, eating, and feeding all meant suffering, and suffering meant redemption” (Bynum 1987, 13). In Holy Anorexia Rudolph Bell equates women mystics with twentieth-century anorexics by contending that both groups display timeless symptoms of the same disease, expressed differently at different points in history (Bell 1985, 56), but Bell’s equation of self-starvation in medieval and contemporary women is to me essentially different. Damaging one’s body without a religious purpose in medieval times would have been entirely against nature and moral principles. However, certain parallels could be established between the ascetic and the anorexic behaviour. Medieval holy

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women’s flagellation and other ascetic practices had the purpose of redeeming sin and attaining spiritual perfection; similarly, the tendency to self-inflicted punishment and pain is a common feature of anorexics under the belief that they do not deserve any kind of pleasure or indulgence, as noted by Claude-Pierre (1997) and as exemplified by Bowman: “she is the guilty one, she deserves nothing. No-thing for her, inside or out” (Bowman 2007, 46). As I will try to illustrate in the next section, the anorexic refusal to eat is frequently connected to low self-esteem, constant self-deprecation and self-inflicted pain that are often manifested by the desire to atone for the (perceived) transgression of eating. In the novels discussed, eating is described as an annoying habit that the protagonist struggles to abandon. Food is an obstacle to the desired low-weight body and the need to eat must be denied (or at least concealed) at any cost; even thinking of food is something to be avoided. The protagonists of all three works narrate how they flush food down the toilet, hide it in the garbage bin, or throw it out of the window. During meals, they stubbornly refuse to eat and spend the whole time pushing food around on their plate or spending endless amounts of time cutting it in minute pieces. The awareness of feeling hungry thus becomes the evidence of a body that is perceived as too big and which needs to be disciplined, as the following section will discuss: She feels her body the whole time … It bothers her now, whereas before it was just there and it didn’t matter. She hates the consciousness of it, but every time she tries to hide it, it seems to tighten its grip – telling her it is hungry, or thirsty, or fat, fat, fat. (Bowman 2007, 23)

Transgression and Punishment Hunger Point offers very interesting parallels between anorexia and religious notions of punishment and penance. Its protagonist Frannie Hunter has grown up observing her mother’s intense love-hate relationship with food. Marsha Hunter is indeed obsessed with eating, although not so much about the food itself but about the rituals she associates with it, which clearly evoke religious practices of alternating excess and asceticism, suffering and temptation, reward and punishment: “the selfrighteous exchange of a gooey brownie for its sugar-free substitute; the sweet surrender of eating off plates when guests leave; and the unfailing reverence for Monday mornings, the beginning of a new week of dieting … this is my mother’s religion” (Medoff 1997, 8). Although the Hunters are nominally Jewish, Frannie often emphasises that her family’s true belief is food: “Even now when people ask about my religion, I just say that in my family we worship the man who invented SnackWell’s”

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(Medoff 1997, 5). The pervading atmosphere of struggling against the evil temptation of food that Marsha Hunter has created is assimilated by Frannie and her younger sister Shelly, who have also learnt to view food and eating as some sort of corrupt force that is constantly trying to lure them into sin and which they must resist: ‘Frannie!’ she yelped. ‘What are you doing?’ I froze in the seat. And slowly, so slowly, I loosened my grip on the forbidden [chicken] skin and slid it palm-down onto my sister Shelly’s plate. ‘Dear’, she said with annoyance, ‘I love the skin more than you, but do you see me eating it? It’s fattening.’ (Medoff 1997, 2)

Unlike Frannie and her mother, Shelly is naturally slim and can thus “afford” to eat fatty food. Later in the novel, however, Shelly begins to put on weight and starts avoiding food: she will develop anorexia and will end up dying as a result. Frannie’s response to this perverse relationship with food is materialised in bingeing episodes in which she completely loses control of herself, after which she vomits and experiences a kind of relief. This feeling of liberation can be simultaneously read as the well-deserved atonement for having infringed the rules: the most disturbing aspect of these vivid descriptions of self-torturing practices is perhaps the reader’s perception that the protagonist derives a strange pleasure in first surrendering to the forbidden act of eating compulsively and then punishing herself for having done so. In Wasted, Marya Hornbacher relates an almost identical relationship with food. After a phase in early puberty in which the protagonist eats compulsively and then vomits systematically, she gradually moves from bulimia to anorexia and significantly begins to struggle against hunger by correlating starvation with moral strength: “Couldn’t we be strong and just eat the toppings, no ice cream? That would have less fat, wouldn’t it? What if we didn’t eat all day, and all the next day, then would it be ok? Bless me father for I have sinned I ate an ice cream sundae” (Hornbacher 1998, 106). She similarly identifies the pain resulting from her refusal to eat with ascetic fasting, substantiated by the belief that such suffering is deserved: “The pain is necessary, especially the pain of hunger. It reassures you that you are strong … In truth, you like the pain. You like it because you believe you deserve it … It is ascetic, holy” (Hornbacher 1998, 124). As seen from Marya’s narrative, the correlation between the perceived weakness of eating and the necessary atonement (in the form of vomiting, using laxatives, exercising or avoiding food altogether) heavily resonates with religious meaning: “She writes of the great weakness that

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drove her to the cupboard and made her eat. The writing is never enough. Confession is insufficient. Absolution never comes in the articulation, only in the penance. She thinks of the saints” (Hornbacher 1998, 86). In all three novels, and quite significantly, sexual relationships are symbolically connected with food inasmuch as they become merely another self-destructive technique, a means of humiliating and punishing themselves. Susan Talberg in Starving Hearts desperately looks for romantic love as a means to find fulfilment and stop feeling inferior, but sexual relationships only make her feel cheap and unattractive: “‘Bobby hasn’t called’, I told Margie. ‘And neither has anyone else. What’s wrong with me, Margie? Why can’t I tempt men?’” (Miller 2001, 52). It is worth noting how Susan correlates food and her body: on the one hand, she views the body she despises as the site of temptation, and therefore it is not strange that she considers sex as loathsome as eating. Moreover, on a symbolic level, she gives away her body to men to feed upon it while she is literally being consumed by her eating disorder. Although the identification between food and body has also been used by other scholars to explain the behaviour of medieval holy women (Bynum 1987), often with the same destructive results, fasting women of the medieval period rejected food with the purpose of approaching saintliness and redeeming sin. Susan, however, has no purpose beyond self-debasement. Frannie Hunter, the protagonist of Hunger Point also bears many similarities to Susan Talberg in terms of her promiscuous sexual behaviour. Frannie also has a best friend, Abby, whom she envies because of the latter’s better looks and success with men. Like Susan, Frannie’s low self-esteem leads her to disastrous relationships: she gets completely drunk on her dates or abuses drugs, and ends up having sex with men who do not have any feelings or respect for her. Actually, her sexual encounters often take place against her will and with a certain degree of brutality. The pervading tone of self-hatred in which Frannie narrates her sexual encounters seems to imply that she uses sex as another means to emphasise the utter contempt she feels for her body. As Frannie tells her psychiatrist: “I’ve learnt to use men the way Shelly used food. To deny myself. I’ve fucked a lot of guys but none that I liked … I didn’t think enough of myself, I think. I gave up the power to speak. Anyway, instead of saying no, I would shut down, hate myself” (Medoff 1997, 357). Marya Hornbacher’s account of her long struggle with anorexia and bulimia in Wasted offers almost identical descriptions of sexual intercourse as a form of punishment to a wayward body, denying it dignity in the same way it is denied nourishment: “Some … use it [sex] as just

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another form of self-destruction, throwing the body around like an old coat, into bed and out of bed with whoever comes wandering by” (Hornbacher 1998, 226). Marya’s relationship with a body she perceives as hateful leads her to have sexual encounters with men she has just met and whom she does not even like, most of which result in an alienating experience: “Sex became a study in dissociation, a physical shutdown, the brain splitting off and watching bodies from above” (Hornbacher 1998, 202). As is the case with Frannie and Susan, both food and sex are used by Marya as a form of self-denial and as a sign of contempt for her body. Her words again evidence our culture’s perception of a woman’s success in controlling her appetite as synonymous with her ability to restrain her passions: My hatred of my body, which steadily escalated over that course of the year and was not, of course, mitigated by the fact that I was losing weight, made it literally impossible for me to be even slightly physical with anyone without feeling disgusting, exposed, dirty, fat … A loose woman, that’s what you are, your passions beyond your control. The etiquette of our culture says that a good woman should take sex and food with a sigh of submission, a stare at the ceiling, a nibble at the crust. (Hornbacher 1998, 112)

All three women thus link their sexuality and their femininity to a body they perceive as disgusting. In a way, both food and sex trigger the protagonists' sense of worthlessness and both reveal a tendency to identify and judge themselves by the response they believe their bodies elicit in male observers, as Janet Wolf has observed: “men look at women. Women watch themselves being looked at. This determines not only the relation of men to women, but the relation of women to themselves” (Wolf 1990, 58). Control of food intake and obsessive exercising under the belief that this sacrifice will reward them with the desired thin body – and, by extension, happiness and success – is thus perceived as the way out of a body and a self that all three protagonists identify as “not good enough”, as the next section will try to illustrate.

Control, Denial and Reward The issue of fasting and control also draws parallels between medieval mystics and anorexic women: by renouncing food and becoming ill, women could escape from the constraints of family duties and conventional female roles. As Bynum notices in Holy Feast and Holy Fast, the role that food practices played in late medieval times is crucial to

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understand why women chose the extreme practice of self-starvation and self-denial that Bynum labels inedia. In medieval Europe, women were associated with food preparation and distribution: by renouncing and distributing the only resource they could control (since economic resources were controlled by male relatives) many devout women controlled their lives and their world. Food abstinence could thus represent a critique of male authority and the rejection of secondary roles within the religious community. Catherine of Genoa (d. 1510), for example, reacted to an unhappy marriage with extreme abstinence, which eventually convinced her husband to lead a life of continence and feeding of the poor and sick. Rita of Cascia (1381-1457) similarly reacted to her husband’s abusive behaviour by wasting away (Bynum 1987, 8). De Beauvoir asserts that the physical limitations that menstruation brings about through nature or culture symbolise the constricted life of a woman in a male-defined and male-dominated society (De Beauvoir 1989, 309-310). In her attempt to explain ascetic practices by medieval holy women, Rebecca Lester proposes an interesting approach that regards the body and its boundaries as a metaphor for the self and food as “the substance that traverses the boundary between ‘me’ and ‘not me’” and argues that food could have been used by both ascetics and anorexics as a metaphor to “negotiate and re-establish the boundaries of the self in response to culturally constructed concerns about gender, sexuality, autonomy, and identity.” By closing the boundaries of the self through fasting (and therefore, not menstruating or excreting) both the ascetic and the anorexic could redefine “the boundaries of the self. The body boundaries may then be crossed only on her authority” (Lester 1995, 190). Christine Battersby similarly points out that woman’s menstrual processes constitute a deviation from the masculine norm, by virtue of which “the female subject has to negotiate the monstrous, the inconsistent and the anomalous” (Battersby 1998, 39). In relation to this, Kristeva’s theory of abjection has two paradigms, the excremental and the menstrual, by which the abject threatens to dissolve the boundaries of the body and the notion of identity: “Excrement and its equivalents … stand for the danger to identity that comes from without … menstrual blood, on the contrary, stands for the danger issuing from within the identity (social or sexual)” (Kristeva 1982, 71). Grace Bowman’s statement seems to exemplify those of Lester and Battersby in her description of anorexia as emulation of asceticism inasmuch as it becomes an attempt to renegotiate the boundaries of the self by restricting food intake: “Best keep everything on the outside clean and tidy so no one can get through to you. … Dirt penetrates just like food, and we must keep it out. Keep the control”

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(Bowman 2007, 30). Anorexic women battle with a self-image they perceive as disgusting and monstrous: an attempt to restrict food (and therefore stop menstruation and excretion) could thus be seen as a wish to regain control over a body they regard as abominable. Bowman exemplifies such fear and anxiety in the following quote: She fears her own shape – it becomes, like a monstrous creation, the seat of all discomfort, pain and anxiety, while the idea of an alternative, thinner shape provides comfort, stability and reassurance. … The body is the enemy, it must be weakened and shrunk and suppressed. It is controllable, it is physical and alterable. … How can she live with herself if this less than perfect body actually is her self? (Bowman 2007, 118-119)

As Elizabeth Grosz contends, “for the girl, menstruation, associated as it is with blood, with injury and wound, with a mess that does not dry invisibly, that leaks uncontrollably ... indicates the beginning of an out of control status” (Grosz 1994, 205). Frannie’s sister Shelly in Hunger Point similarly provides a striking image of the anorexic feeling of otherness within the body she inhabits and her struggle to achieve self-fulfilment and peace of mind: she keeps a diary in which she expresses the ultimate goal she is striving toward, which she ends up dying for. The passage illustrates how Shelly’s aspiration has clear connotations of religious fervour; her language expresses her feeling of inadequacy and intensely resonates with the female mystic’s longing to dissolve her bodily existence and reach union with God: There’s a hidden place deep inside myself I’m trying to reach. A calm, quiet place where I don’t exist as a girl with a body that grows too big. A place where I can finally sleep … The point where I’m so hungry, I can’t feel it, the point of numbness, suspension, the window of time when it’s okay to say yes, to let go, to fly. That’s the point I walk toward, my own personal hunger point; a point where I feel everything and nothing at all. When all it takes is one more step and I’ll be safe. (Medoff 1997, 334)

Marya’s account of the advent of puberty also correlates the onset of menstruation with the perception that her body has gone out of control: “Without warning, my body began to ‘bloom’. I woke up one morning with a body that seemed to fill the room” (Hornbacher 1998, 40). Marya’s feeling of otherness within her pubescent body also seems to mark the aggravation of her disorder, reproducing a wish to escape that once again reverberates with the ascetic yearning to transcend a body that is perceived as a prison to the self: “I had this idea in my mind that dying would be lovely, a simple loosening of the ankle shackles that held me to the

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ground. I would lift off into the sky, float over the iced white streets” (Hornbacher 1998, 181). According to Bowman, “we equate our success with how much we weigh. The end result of this fixation must surely be that this denial and control actually become what we are about” (Bowman 2007, 126). The issue of achieving a sense of control by denying hunger is acknowledged in Wasted, where Marya equates her refusal to eat with “something like power”: as she narrates, “by controlling the amount of food that goes into and out of you, you imagine that you are controlling the extent to which other people can access your brain, your heart” (Hornbacher 1998, 68). Marya’s account reveals that a woman’s ability to control her food intake and tolerate hunger and pain is perceived by our culture as a sign of success and moral fortitude: When a woman is thin in this culture, she proves her worth, in a way that no great accomplishment, no stellar career, nothing at all can match. We believe she has done what centuries of a collective unconscious insist that no woman can do – control herself. A woman who can control herself is almost as good as a man. (Hornbacher 1998, 82)

One infers, therefore, that a woman’s inability to be thin can be culturally attributed to a weakness on her part, a lack of moral standing and a sign of failure that cannot be compensated by other achievements. The next section will examine the religious aspects mentioned so far in the context of family, environment and culture as informed by the three novels analysed.

The Family Religion: Cultural Assumptions on the Female Body The anorexic attempt at control against the pressing demands of hunger in the novels seems to be strongly influenced by culture, environment and family, and it is mostly evidenced through the female role models impersonated by the protagonists’ mothers. Significantly, the mother figures in all three books (Judy Hornbacher in Wasted, Marsha Hunter in Hunger Point and Jean Talberg in Starving Hearts) seem to have embraced the religious aspects so far discussed and passed them onto their daughters – that is, an equation of thinness with success that demands controlling and resisting the temptation of food, along with the punishment they deserve if they fail to do so. The cliché of the over-affectionate and over-protective mother-hen is here distorted: the mother figures appear

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unhappy and dissatisfied, thus likely to project their frustrations onto their daughters instead of providing a positive female model for them. For Marsha Hunter, Frannie’s mother in Hunger Point, being on a constant diet is an act of womanly dignity and responsibility as it constitutes a barometer of her moral duty to struggle against weakness (that is, succumbing to the temptation of food) and preserve a slim and attractive appearance. She acts more like an older sister and therefore fails to provide a positive image of female adulthood to her daughters: rather than providing affection and support, most of Marsha’s advice consists in instructing her daughters on the best ways of dieting and misusing drugs. An instance of Mrs. Hunter’s failure as a mother is made patent in her conversation with Susan after visiting Shelly in hospital, in which Marsha is incapable of accepting the gravity of her daughter’s disease: ‘They say it’s one of the best hospitals for …’ She trails off as she makes her way onto the FDR drive. ‘For what?’ Say it, Mom, just say what it is. I feel my rage toward her building, but keep silent and swallow hard. ‘Dear,’ she says in the tired voice usually reserved for my grandfather. ‘Don’t start.’ ‘You should just say what it is. It’s anorexia, Mom. An eating disorder. It’s like being addicted to alcohol or heroine or, I don’t know …’ I pause. ‘Valium. Maybe if you were able to say what it is, she wouldn’t be in hospital’ (Medoff 1997, 25)

In Starving Hearts, the narrator’s mother similarly places great value on etiquette and stages every meal in the dining room: as an exemplary homemaker, Jean Talberg spends hours cooking delicious and highly sophisticated dishes and ascribes great importance to food. As opposed to Mrs. Hunter, however, Jean Talberg does not encourage her daughter Susan to diet but just the contrary. Her worship of food has been marked by childhood poverty, so she expects her family to praise her meals profusely and tells her daughters horrifying stories of her past if they fail to empty their plates. The reader immediately dissociates the Talbergs’ dining table from the usual connotations one derives from a family gathering at home – that is, cosiness, warmth and affection – and instead senses Susan’s discomfort at the pervading tension, formality, stiffness and overstatement: “I will always remember our dining room as the scene of every emotional turmoil I ever had … My digestive system reacted like a frightened pony. My stomach churned acid foam all over my mother’s food and my intestines recoiled into knots of pain. Still, I ate” (Miller 2001, 40). Susan Talberg therefore associates her mother’s dominant personality with the food she is forced to eat, and starts seeing both as

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enemies. When Susan stops eating and becomes anorexic, she effectively refutes her mother and the domestic values she represents. Like Marsha Hunter in Hunger Point, Mrs. Talberg is constantly on a diet and advises Susan’s sister Debby to control what she eats. Susan, on the contrary, is not required to watch her appetite because of her slender constitution, and this causes both her mother and sister to be terribly jealous of her. Jean Talberg is described by her daughter as a monster: Susan openly states that she hates her mother and loves her father, a warmhearted yet weak man who never shows affection toward his wife but nevertheless avoids confronting her domineering personality. The power relationships in the Talberg family are later replicated in Susan’s unhappy marriage to Michael, another insecure man and the former boyfriend of her friend Margie. Margie is popular with men and has a healthier approach toward sexuality, but Susan’s low self-esteem makes her feel ugly and unworthy of any man’s affection. While desperately looking for emotional fulfilment and having unrewarding sexual relationships, Susan secretly adores Michael and cannot understand why Margie has deserted him. Susan disregards Margie’s reasons for breaking her relationship with Michael and marries him, only to discover he is emotionally unstable. When he starts physically abusing her, Susan threatens him that her father is going to kill him in revenge, but Michael opens her eyes to her parents’ relationship: “‘Oh, no, he won’t,’ said Michael. ‘He’ll wish he’d had the courage to do the same thing to your mother. Face it, Susan. Your father is a wimp. Your mother is the man of the house’” (Miller 2001, 199). Marya Hornbacher’s mother Judy in Wasted is portrayed as a distant, unaffectionate mother whose professional achievements appear to have been handicapped by marriage and motherhood. Such frustration seems to be channelled in her display of an unhealthy relationship with food and with her body, mainly exemplified by constant exercise, refusing to eat, and obsession with her image. As Marya narrates, “both of them [parents] used food – one to excess, one to absence – as a means of communication, or comfort, or quest. Food was a problem in my family” (Hornbacher 1998, 22). Apart from showing how food and body become a signifier of the Hornbachers’ conflictive marriage, Marya’s narrative remarks that Judy’s obsession with dieting and fitness is not only a family issue but part of a cultural statement that associates women’s bodies with certain social values: “Taking part in the fitness craze requires time and money, a privilege available to those only with the means. The ‘perfect body’ becomes a public display of those means” (Hornbacher 1998, 46). As Judy turns forty and Marya approaches puberty, Marya notices how her mother becomes increasingly concerned with her appearance. In turn, Marya’s

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perception that her mother is disappointed with her seems to be connected with her own struggle with weight, which is evidenced by the following scene: We picked at our food, competing for who could eat the least … When my mother was a kid, fat people were perceived by her family as slightly lesser beings. Fat people were lower class and were thus sneered at. In their opinion, fat people could not control themselves, not like the perfect little Williams family with their perfect skinny genes … Poor woman, giving birth to a normal-sized child. Could I possibly come from her body, this little round being? (Hornbacher 1998, 98)

Judy remains distant and unsupportive even in the face of Marya’s descent into bulimia and anorexia, ignoring the plain evidence that Marya is rapidly losing weight and looking unhealthy. Instead of being alarmed by Marya’s weight loss, Judy refuses to acknowledge that fact with a sneering remark that seems to imply that Marya’s thinness has apparently not yet reached the satisfactory level of “thin enough”: “Trying to get some visual perspective on myself and practicing my Affirmations, I will declare: I’m pretty thin. And my mother will respond: I wouldn’t call you thin” (Hornbacher 1998, 100). It is therefore not strange that Marya persists in her refusal to eat without being aware of the fatal consequences this might have on her health, since her perverse relationship with food and her hatred of her body are not only represented by her mother but by other women as well: “Of course I didn’t know then that I had all the obvious signs of having an eating disorder … Part of the reason I didn’t notice was because what I was doing was hardly unique” (Hornbacher 1998, 107). Marya’s alarming remark reveals that unhealthy dieting and overconcern for one’s appearance are embedded in our culture and affect large numbers of women, far beyond those who are clinically diagnosed with anorexia: “There are precious few women who eat normally. You get out of the hospital, look around at what other people are eating, and realize the nice little meal plan you’re on – though you need it to stay healthy – is not the norm” (Hornbacher 1998, 217). Thus, the need to police one’s body in order to fulfil the cultural ideal of slenderness has become, as Marya reflects, a generalised perception that not only affects anorexic women but also those who are considered “normal” and “healthy”: We grew up with the impression that underneath all this normal flesh, buried deep in the excessive recesses of our healthy bodies, there was a Perfect Body just waiting to break out. It would look exactly like everybody else’s perfect body. A clone of the shapeless, androgynous models, the hairless, silicone implanted porn stars. (Hornbacher 1998, 47)

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As well as the two other novels discussed, Wasted provides an abundance of examples that such a distorted perception of the reality of women’s bodies extends far beyond anorexic women. When a visitor to the hospital where she is staying for treatment mentions that she looks like a model, Marya is delighted by the comment and fails to realise the perversity of this comparison, as the appearance the visitor is praising is precisely the reason for her stay in hospital – that is, a degree of thinness that is completely unhealthy and even life-threatening (Hornbacher 1998, 182). Evidence of the same contradiction is very aptly expressed by Bowman: “How could my body be the object of all this attention and everincreasing shouting, thumping pressure, when the pages of the magazines told me that I was emulating, and that I was emulating well?” (Bowman 2007, 126). While Marya is probably too young and emotionally unstable to consider the serious damage that she is doing to her health, Judy’s detachment fails to provide the necessary support to help her daughter, seemingly because Judy is unable to help herself against the social predicaments that command thinness in a woman. Evidence of Judy’s entrapment in the cult of thinness and her resulting inability to help her daughter can be found after Marya is admitted to hospital. As she reflects upon her family’s conflictive relationship with food and tries to discuss the issue with her mother during one of her visits, she refuses to acknowledge her part of the responsibility for her daughter’s illness and instead attributes her disorder to some sort of shortcoming of her own: I mentioned that she was perhaps a bit overconcerned with her own body, her weight, how much she ate. She sat in her metal hospital chair, arms crossed, fingers flickering, smiling a patronizing smile. I pressed her. The smile turned nasty, and she announced that I had no business blaming her for my problems. I said, I’m not blaming you, I’m just saying I might have picked up some habits – She said, Sweetheart, you didn’t pick anything up. You just came this way. (Hornbacher 1998, 156; emphasis in original)

Judy’s remark resembles the attitude of the other two mother figures analysed here in denying their part of the blame for their daughters’ illness. Meanwhile, as Bowman asserts, it reflects social cynicism in fostering cultural values that equate women’s success with extreme thinness and then refusing to take responsibility for them: “The most disturbing of these conclusions is seemingly one of the most prevalent among the medical profession and public – the belief that the anorexic is to blame” (Bowman 2007, 48). In short, Judy Hornbacher, Marsha Hunter

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and Jean Talberg seem to be perpetuators as well as victims of the destructive consequences of embracing cultural assumptions about the female body. All three women display an over-confident mask of assertiveness in their emotional detachment and manipulative behaviour: their strong personalities and their appearance of fortitude, then, do not equate to a powerful female role model as they only hide the frustration and dissatisfaction that they project onto their daughters. Ultimately, all three women are incapable of instilling the notion of self-respect and selfesteem into their daughters because they seem to lack it themselves.

Conclusions Claudine Herzlich and Janine Pierret contend that physical illness or illness of a psychosomatic nature can emerge in the face of an unbearably excruciating conflict or situation and can therefore be the expression of a revolt of someone’s entire being. In the case of a severe or life-threatening illness, the sufferer might regard it as a sign of failure or defeat in life, materialised and made visible in the body (Herzlich and Pierret 1987, 123124). Anorexia is perhaps one of the most outstanding examples of this correlation, since the anorexic woman’s perception of herself as a failure is powerfully signified by her body: as Young asserts, “women in sexist society are physically handicapped. Insofar as we learn to live out our existence in accordance with the definition that patriarchal culture assigns to us, we are physically inhibited, confined, positioned, and objectified” (Young 2005, 42). Anorexics identify themselves not as a presence but as an absence: denying themselves food (and, therefore, nourishment and health) stands for their rejection of the pleasure, the happiness and the life they believe they do not deserve. Through starving or vomiting, the anorexic woman is able to communicate what she is not, what she refuses to integrate in herself. The Duchess of Windsor’s alleged statement that “a woman can never be too rich or too thin” is substantiated by research: as Wolf quotes, forty-five per cent of women who can be clinically considered underweight actually hate themselves because they believe themselves to be fat (Wolf 1990, 185). The case of anorexic women takes this assumption to its most frightening extreme, as the point of being “thin enough” is never reached. Going on a diet seems to be the solution to regain self-esteem and achieve peace of mind: problems and contradictions will disappear once the ideal weight is attained – what Shelly Hunter calls her “personal hunger point” (Medoff 1997, 334). What had initially started as a diet, however, goes out of control and the anorexic continues to starve because she still views herself as inadequate,

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unworthy, and a stranger to herself. Toril Moi’s notion of the “lived body” breaks up (or rather reunites) the categories of sex and gender to account for the experience of a woman’s unique body as conditioned by the specific conditions that influence her situation of being a woman in a given sociocultural context (2001). In this view, the body can be both a culture producer and a cultural product. In the same way that control of food and appetite constituted a powerful metaphor for a woman’s social position and moral stature in the medieval period, modern dieting and contemporary cultural assumptions about the female body are crowded with references to religious concepts such as suffering and self-denial, temptation and sin, punishment and reward. Many women today struggle to control their appetites and are not capable of enjoying most of what they eat without counting calories, feeling guilty and thinking of how many fitness sessions will make amends for the food they have eaten. As Herzlich and Pierret assert, “if the meaning of our illness is within ourselves, it remains almost always obscure to us” (Herzlich and Pierret 1987, 125). Similarly, as Bowman contends, The theories on anorexia nervosa pile on top of one another; they do not make sense. They contradict and argue over causes and issues and blame. The public fight over our bodies ends up marginalizing many and compartmentalizing others. No wonder the illness did not make sense to me, nor is it clear to many others now. (Bowman 2007, xiv)

Anorexia nervosa is still unfortunately an obscure disease for us citizens at large, its causes still indeterminate for both specialists and patients. A reading of the cultural meanings inscribed in narratives of anorexia, however, might perhaps lead to a better understanding of its processes, if not of its causes.

References Banks, Caroline G. 1996. “‘There is No Fat in Heaven’: Religious Ascetism and the Meaning of Anorexia Nervosa.” Ethos 24.1: 107135. Battersby, Christine. 1998. Phenomenal Woman: Feminist Metaphysics and the Patterns of Identity. New York: Routledge. Bell, Rudolph M. 1985. Holy Anorexia. Chicago, IL: University of Chicago Press. Bordo, Susan. 1993. Unbearable Weight: Feminism, Western Culture, and the Body. Berkeley, CA: University of California Press.

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Bowman, Grace. 2007. Thin. London: Penguin. Bruch, Hilde. 1978. The Golden Cage. Cambridge, MA: Harvard University Press. Brumberg, Joan J. 2000. Fasting Girls: The History of Anorexia Nervosa. New York: Vintage Books. Bynum, Caroline W. 1985. “Fast, Feast, and Flesh: the Religious Significance of Food to Medieval Women.” Representations 11: 1-25. —. 1987. Holy Feast and Holy Fast: The Religious Significance of Food to Medieval Women. Berkeley, CA: University of California Press. Chernin, Kim. 1985. The Hungry Self: Women, Eating and Identity. New York: Times Books. —. 1981. The Obsession: Reflections of the Tyranny of Slenderness. New York: Harper & Row. Claude-Pierre, Peggy. 1997. The Secret Language of Eating Disorders. New York: Times Books. De Beauvoir, Simone. 1989. The Second Sex, translated by H. M. Parshey. New York: Random House. Dimulescu, Venera. 2015. “Contemporary Representations of the Female Body: Consumerism and the Normative Discourse of Beauty.” Symposion 2.4: 505-514. Grosz, E. 1994. Volatile Bodies. Bloomington, IN: Indiana University Press. Herzlich, Claudine and Pierret, Janine. 1987. Illness and Self in Society, translated by Elborg Forster. Baltimore, MR: Johns Hopkins University Press. Hesse-Bieber, Sharlene. 1996. Am I Thin Enough Yet?: The Cult of Thinness and the Commercialization of Identity. New York: Oxford University Press. Hornbacher, Marya. 1998. Wasted. New York: HarperCollins. Kristeva, Julia. 1982. Powers of Horror. New York: Columbia University Press. Lester, Rebecca J. 1995. “Embodied Voices: Women’s Food Asceticism and the Negotiation of Identity.” Ethos 23.2: 187-222. Medical Dictionary Online: http://medical-dictionary.thefreedictionary.com/anorexia [accessed 25th January 2016]. Medoff, Jillian. 1997. Hunger Point. New York: Regan Books. Miles, Margaret R. 1995. “Religion and Food: The Case of Eating Disorders.” Journal of the American Academy of Religion, Thematic Issue on “Religion and Food” 63.3: 549-564. Miller, Lynn R. 2001. Starving Hearts. Pacifica: Excentric Press.

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Moi, Toril. 2001. What Is a Woman and Other Essays. Oxford: OUP. Seid, Roberta P. 1989. Never Too Thin: Why Women Are at War with Their Bodies. New York: Prentice Hall. Weinstein, Donald and Bell, Rudolph M. 1982. Saints and Society: The Two Worlds of Western Christendom, 1000-1700. Chicago, IL: University of Chicago Press. Wolf, Naomi. 1990. The Beauty Myth. London: Vintage Books. Young, Iris M. 2005. On Female Body Experience: “Throwing Like a Girl” and Other Essays. Oxford: OUP.

CHAPTER ELEVEN WILKIE COLLINS’ HEART AND SCIENCE AND THE AXIOLOGICAL INDETERMINACY OF MEDICAL DISCOURSE EMANUELA ETTORRE

The aim of this chapter is to interrogate the progress of nineteenthcentury medical science as it was both reflected and conceptualised in Heart and Science, a late Victorian sensation novel written by Wilkie Collins in 1883. By adopting the thematic devices of sensationalism, such as blackmail, insanity, hatred, jealousy, mystery, long trips and confrontations, Heart and Science 1 exemplifies the epistemological disorientation of the Victorians. In its portrayal of the medical profession and its exponents, it reveals the moral ambivalence and propensity for the perverse that normally characterise sensational heroes and heroines, significantly undermining the conventional, laudatory characterization of the emergent category of the doctor as a man of science. In one of the two Prefaces to Heart and Science,2 Wilkie Collins alludes not simply to the presence of “medical practice” and “physiological questions” within his novel, but also to the authenticity and accuracy of his scientific material,



1 Heart and Science was serialised in Belgravia from August 1882 to June 1883 and published in three volumes by Chatto and Windus in 1883. Mainly considered an antivivisection novel, it was defined by Wilkie Collins himself as a book written “in vitriol and dynamite” (Baker and Clarke (eds.) 1999, 447). Heart and Science: A Story of the Present Time, 1996, ed. by Steve Farmer, Peterborough, Ontario: Broadview Press. All quotations in this text will be from this edition, with the indication of the page number. 2 Wilkie Collins tried to explain his ideas not only to a large public but also to a more specific category of literary men and professionals, thus dividing the Preface to Heart and Science in two sections: “To Readers in General” and “To Readers in Particular”. The quotations above refer “To Readers in Particular” (Collins 1996, 39).

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by reference to actual and up-to-date documents of eminent physiologists such as the ones by David Ferrier on the localization of cerebral disease.3 Even though the paradigm of vivisection is explored only in the second half of the novel, and its hideous secrets are never explicitly unveiled, Heart and Science also testifies to Collins’ serious commitment to the scientific debates of his time, to his wide interests in medicine and psychiatric theories, and his investment in the ethical issues they inevitably entail. Thanks to a certain freedom granted by the sensational genre, which challenges the constrictions of a clear-cut dichotomy of good/evil and order/disorder, Collins introduces medical discourse into the narrative in order to better expose the more disquieting aspects of the human psyche, the convolutions of the mind, and his interest in the unwonted expressions of individual passions.4 In this novel, more than one character is therefore connected to the domain of science: Ovid Vere, the brilliant and sensitive young doctor, entirely devoted to the development of medicine for the benefit of humanity; Dr. Nathan Benjulia, rendered (at least initially) as a typical sensational villain, an unscrupulous and ambitious vivisectionist whose interests in the causes and treatment of brain disease lead him to conceive of medicine as a pursuit that lies beyond the sphere of morality; and Mrs. Maria Gallilee, Ovid’s mother, the prototype of scientific dilettantism, whose concern for the “Diathermancy of ebonite”, the “Interspatial Regions” (126), along with botany and geology, is shown in her attempts to organise parties, host lectures, and give demonstrations in the magnificent rooms of her house. 5 Alongside these three main characters, the novel also introduces the figure of Dr. Null, a weak and

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Significantly, in 1881 David Ferrier was accused of violating the restraints imposed on vivisection for stimulating the brains of live animals even after they had awakened from the anaesthesia. In order to examine the cortex in depth he also experimented on animals using electricity. For an analysis of Ferrier’s researches and their resonance within the late Victorian antivivisection debate, see Otis 2007, 27. 4 As Anne Cvetkovich observes, the power of sensationalism lies in “the rendering visible of what remains hidden or mysterious”; in this sense the strategies of sensationalism perfectly converge in the choice of a novel that aims at disclosing the secret spaces of the laboratory and the deceptiveness of science (Cvetkovich 1992, 24). 5 The ironic tone of the narrator is frequently directed to Mrs. Gallilee’s pseudoscientific activities that make her “familiar with zoophyte fossils” as well as with the dissection of “the nervous system of a bee” (71). She is also keen on the dissection of flowers and on “coprolites, […] the fossilised indigestions of extinct reptiles” (111).

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incompetent family physician whose ineffective approach towards medicine is clearly evoked by his peculiar name.6 But it is through the perturbing figure of Dr. Nathan Benjulia that Collins tries to penetrate the complexities of scientific speculations and the ambiguous feelings that the Victorian public at large had about physiology and vivisection. The cynical physician allows Collins to attack the dehumanising consequences of scientific methods, express his apprehension for the brutalities inflicted on animals in the laboratory, and illustrate the devastating effects of vivisection on the psyche of the physician who practises it. As Collins himself wrote in a letter to Frances Power Cobbe in 1882, the main aim of Heart and Science was to reveal the moral impact of vivisection on the nature of the practitioner, and to show the efforts made by his better instincts to resist the “inevitable hardening of the heart, the fatal stupefying of all the fine sensibilities, produced by the deliberately merciless occupations of his life” (Baker and Clarke 1999, 447). The Victorian sensational writer was well aware that the contemplation of pain could degrade the human soul and lead to a morbid behaviour marked by violence and perversion. Thus, his cynical representation of the “archvivisectionist” seems to play on, anticipate, and even accentuate one of the features of modernity that Susan Sontag defines as the “innate tropism toward the gruesome”, that is, the tendency to “yield, even if reluctantly, to repulsive attraction” (Sontag 2004, 86-87). Therefore, any spectators of cruelties can gradually manifest a macabre enthusiasm that often degenerates to the point whereby what they are witnessing itself becomes enticing. Quite significantly, even Lewis Carroll in 1875, writing against the infliction of pain on animals in his famous essay “Some Popular Fallacies about Vivisection” maintained: […] man has something of the wild beast in him, that a thirst for blood can be aroused in him by witnessing a scene of carnage, and that the infliction of torture, when the first instinct of horror has been deadened by the familiarity may become, first a matter of indifference, then a subject of morbid interest, then a positive pleasure, and then a ghastly and ferocious delight. (Carroll 1988, 1076-1077)

Wilkie Collins was well acquainted with the vivisection debate of his time – a debate in which even Charles Darwin had a prominent place. In a letter to Professor Ray Lancaster in 1871, Darwin argued that vivisection

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“Mr Null, professionally and personally, was incapable of stepping beyond his narrow limits, under any provocation whatever. He submitted to the force of events as a cabbage-leaf submits to the teeth of a rabbit” (297).

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was “justifiable for real investigations on physiology; but not for damnable and detestable curiosity. It is a subject which makes me sick with horror, so I will not say another word about it, else I shall not sleep tonight” (Darwin 1958, 304). Ten years later, when a series of Acts of Parliaments and Bills had in part regulated experimentation on animals, he straightforwardly stated: “physiology cannot possibly progress except by means of experiments on living animals, and I feel the deepest conviction that he who retards the progress of physiology commits a crime against mankind” (Darwin 1958, 306). During the last decades of the nineteenth century the scientific world was therefore divided between staunch supporters of experimentation, mostly the followers of Claude Bernard’s scientific determinism, and a group of activists led, among others, by Frances Power Cobbe, who wanted to restrict, if not abolish, the practice of vivisection through petitions, articles and the monthly periodical The Zoophilist.7 Wilkie Collins’ preoccupation with the savagery of vivisection was mainly connected to the venomous impact that those cruelties had on the moral character of the man who practised it; as he wrote in a letter to Power Cobbe with reference to his protagonist Dr. Benjulia: “I shall be careful to present him to the reader as a man not originally wicked and cruel” (Baker and Clarke 1999, 446). It is therefore the practice of an inhumane scientific occupation that transforms, deviates and degrades Benjulia, and thereby throws into doubt the civilising influence of medical science, suggesting that instead it might corrupt and debase those who practised it, and even throw into jeopardy the human beings it was supposed to serve. Heart and Science is composed of two narratives: a marriage plot centred on the love story between Ovid and Carmina, which is constantly obstructed by Ovid’s mother and her accomplices, and the scientific plot related to Dr. Benjulia’s attempt to discover the cure for hysteria, and his parallel activity as a vivisectionist, firm in his conviction that the same forms of medical experimentation can be equally applied to man and animals. The two plots are inevitably intertwined, as Carmina’s nervous

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The Zoophilist was used as a propaganda vehicle for the antivivisection society founded by Frances Power Cobbe on 2 December 1875 (named the Society for the Protection of Animals Liable to Vivisection and later known as the Victoria Street Society). In 1881 the Victoria Street Society published the first edition of The Zoophilist. As Theodore G. Obenchain observes: “This monthly carried a potpourri of antivivisection news, such as articles on animal cruelty, failures of vivisection or major differences of scientific opinion between physiologists. Another recurrent column was devoted to “Physiological Fallacies,” in which the editors openly disagreed with vivisectors on a variety of scientific points” (Obenchain 2012, 88).

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breakdown – caused by the psychological violence Mrs. Gallilee inflicts on her during her son’s absence – becomes a case study for Dr. Benjulia. His obsessive interest in brain disease stops him from treating Carmina’s “hysterical disturbance” (280) in the hope that he will be able to contemplate her inexorable worsening and conduct a post-mortem examination of her brain.8 If in the first plot the love story will be fully realised, in the second one the machinations of the man of science will decide his downfall. Nevertheless, both narratives are a rich source of sensationalism, as they converge in the textualization of extreme passions and transgression, in the hyperbolic villainy and inhumanity of Mrs. Gallilee and Dr. Benjulia, both of whom are captivated by science. Collins’ attempt to associate and almost subordinate the scientific debate on vivisection to a melodramatic love plot is partly justified by the general tendency of Victorian antivivisectionists to conjoin the rights of animals and feminist issues. As Anne Dewitt observes in her study on moral authority and men of science, the antivivisection movement also “illuminates the role of gender in the vivisection debates and women’s relationship to science in the late nineteenth century” (Dewitt 2013, 127). Moreover, women were identified with the tortured animals on which the physiologists experimented; as a matter of fact, in this novel the female characters are not (or not simply) conceived of as passionate and seductive creatures. Just like test animals, they become instead a case study for the scientists: the delicate and almost ethereal Carmina is subjected both to the incompetence of Dr. Null and to the cruelty of a vivisectionist who treats her hysterical disturbance “as gratifying an interest in the case as ever” (280). From Nathan Benjulia, therefore, “Carmina was destined to receive unknown honour: she was to take her place, along with the other animals, in his note-book of experiments” (280). Even Benjulia’s cook is a vigorous little woman, towards whom the physician “pursued his own ends […] just as he pursued his own ends with a vivisected animal” (214). He considers her as an “inferior creature” and looks at her “(experimentally) […] as he looked (experimentally) at the other inferior creatures stretched under him on the table” (215). Because of her incapacity to prepare perfect mutton in due time and because of a certain impertinence with which she treats him

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It is interesting to observe that even in Thomas Hardy’s The Woodlanders (1887), a novel apparently dissociated from scientific disquisitions and set in the topographies of rural England, the figure of the doctor is associated to an innate form of insensitiveness and sadism. The mysterious physiologist Dr. Edred Fitzpiers offers ten pounds to an old and ailing woman, Grammer Oliver, compelling her to sign an arrangement in order that he might have her skull after her death as a “subject for dissection” (Hardy 2009, 117).

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by hugging him ardently, Dr. Benjulia heartlessly induces her to have a hysterical reaction. He is interested in her emotional response, since “a moral shock sometimes has a serious effect on the brain – especially when it is the brain of an excitable woman. […] [I]t had just struck Benjulia that the cook – after her outbreak of fury – might be a case worth studying. But, she had got relief in crying; her brain was safe; she had ceased to interest him” (217). Noticeably, as Heather Ellis observes in her speculations on medical authority as a gendered ideal, the power of medical science conflates with the “male ascent and the affirmation of masculine authority through scientific discourse and practice” (Ellis 2017, 3). Dr. Benjulia reinforces this idea in his obsessive and perverse attempt to undermine the realm of femininity that is often represented in its most vulnerable and feeble nature. Even Mrs. Gallilee is doomed to suffer from “a severe shock […] involving mental disturbance as well as bodily injury”; a case of “violent madness” (296) that compels her relatives to confine her temporarily in a private asylum. Women are depicted as powerless creatures, often prone to nervous diseases and either characterised by extreme weakness (Carmina) or by an irreducible wickedness (Mrs. Gallilee). In Wilkie Collins’ novel the unstable female body is converted from an object of desire into an object of study. 9 As the narrator notes when describing Dr. Benjulia’s relationship with women: “There are many men […] who are not fit persons to be in the company of young girls – but they are either men who despise, or men who admire, young girls. Benjulia belonged neither to the one nor to the other of these two classes. Girls were objects of absolute indifference to him” (179, italics added). In Heart and Science Collins exploits the female hysterical disturbance not only to suggest a widespread male perception of the woman’s body as problematic, or to connect the nervous disorder to the transgression of social and sexual principles, but

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Quite significantly, when Carmina is ill, Wilkie Collins seems to have well in mind the scientific theories Darwin advanced in The Expression of Emotions in Man and Animals in which the sufferers from “an acute paroxysm of grief […] no longer wish for action, but remain motionless and passive […] the circulation becomes languid; the face paler; the muscle flaccid; the eyelids droop; the head hangs on the contracted chest; the lips, cheek and lower jaw all sink downwards from their own weight (Darwin 1999, 176-177). In Heart and Science, after the shock, Carmina is thus described: “A ghastly stare, through half-closed eyes, showed death in life, blankly returning her look. The shock had struck Carmina with a stony calm. She had not started, she had not swooned. Rigid, immovable, there she sat; voiceless and tearless; insensible even to touch; her arms hanging down; her clenched hands resting on either side of her” (250).

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mainly to interrogate the ambivalent moral standards of medical science.10Alongside the threat of blackmail, deceit, illegitimacy and the most bewildering secrets and shocking revelations, medical science becomes one of the main forms through which sensationalism comes to the fore. It is a “Savage Science” (136), as the narrator aptly defines it, a potentially subversive activity, the expression of wicked minds, pursued for ignoble objectives. It often alters the equilibrium of family life and instead of representing relief from a disease or an instrument of knowledge, it becomes either an attempt to achieve fame, or an exhilarating occupation for unsatisfied ladies within the high bourgeoisie. Nevertheless, and almost paradoxically, Wilkie Collins seems to be interested in the disquieting outcomes of science. To use Roland Barthes’ words: “He suspected Science, reproaching it for […] its adiaphoria11 […] Yet […] he liked the scientists in whom he could discern a disturbance, a vacillation, a mania, a delirium, an inflection” (Barthes 2010, 160). And Nathan Benjulia is portrayed exactly according to these distinctive traits and disposition, in order to guarantee the most sensational effects to the story: his obsession with the study and treatment of brain diseases makes him the most intriguing character in the novel. Consumed by ambition and hunger for glory, he is tempted by the most perilous risks of science that John Ruskin identified in its “insatiableness and immodesty” (Ruskin 1904, 85): as he realises that a rival has anticipated his discoveries, and himself prey to madness, he liberates the host of animals on which he experimented, burns down his own laboratory, and commits suicide. When science exceeds the limits of morality and common sense, when it loses wisdom and its “power of modesty” (Ruskin 1904, 74), a failure risks becoming a degrading defeat, or a humiliation that degenerates into selfpunishment and death. As Ruskin further observes in one of his lectures on the power of modesty in science and art: “[t]he fatallest furies of scientific aphrosuné12 are consistent with the most noble powers of self-restraint and self-sacrifice. It is not the lower passions, but the loftier hopes and most honourable desires which become deadliest when the charm of them is exalted by the vanity of science” (Ruskin 1904, 85-86). Notwithstanding

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On the medicalization of femininity Tabitha Sparks tellingly notes: “the sick woman, on the verge of either death or recovery and marriage, embodies the contest between moral and immoral science” (Sparks 2009, 108). On the representation of the female body and its nervous disorders see also: Wood 2001. 11 The Greek word adiaphora indicates “indifferent things”, and according to Stoic philosophy, it referred to things that were neither good nor bad, that is, outside the ethical principles. 12 Foolishness, wickedness.

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the most honourable premises and objectives of science, it is precisely this sense of vanity, the excessive pride hidden behind a simulated commitment for the profit of humanity that leads Dr. Benjulia to his delirious confession: Am I working myself into my grave, in the medical interests of humanity? That for humanity! I am working for my own satisfaction – for my own pride – for my own unutterable pleasure in beating other men – for the fame that will keep my name living hundreds of years hence. Humanity! I say with my foreign brethren – Knowledge for its own sake, is the one god I worship. Knowledge is its own justification and its own reward. The roaring mob follows us with its cry of Cruelty. We pity their ignorance. Knowledge sanctifies cruelty. The old anatomist stole dead bodies for Knowledge. In that sacred cause, if I could steal a living man without being found out, I would tie him on my table, and grasp my grand discovery in days, instead of months. (190, italics mine)

The paradigmatic sequence satisfaction-pride-pleasure-fameknowledge-reward inevitably places the sphere of medical science within an “epistemology of passions”, a passionate excess, an “immoderate desire” (Greimas and Fontanille 1993, 69), an obstinate form of greed and avarice that drives people to keep knowledge for themselves, thus refusing to accord any value to munificence and altruistic drives. As a consequence, the thirst for knowledge advances regardless of its methods and the suffering it may inflict; in turn, cruelty becomes the dysphoric category subsuming all science and its exponents. Nevertheless, since the sensation novel emphasises the potential moral duplicity of its characters and the unstable nature of their probity, even in Heart and Science the representation of the scientist respects this axiological indeterminacy. Dr. Benjulia’s deranged mind, together with his conflicting ideas on vivisection, offers a striking portrait of a man tortured by the shocking consequences of his scientific passion. And it is precisely when he tries to explain to his brother Lemuel the effects of an experiment conducted on a sick monkey, that we perceive Collins’ intent to portray the physician as an “object of compassion as well as of horror” (Baker and Clarke 1999, 447): Have I no feelings, as you call it? My last experiments on a monkey horrified me. His cries of suffering, his gestures of entreaty, were like the cries and gestures of a child. I would have given the world to put him out of his misery. But I went on. In the glorious cause I went on. My hands turned cold – my heart ached – I thought of a child I sometimes play with – I suffered – I resisted – I went on. All for Knowledge! All for Knowledge! […] His dark face turned livid; his gigantic frame shuddered; his breath

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The feeling of repugnance produced by Dr. Benjulia’s cynicism and “innate insensibility” (131) is also balanced by a certain humanity that he expresses in his affection towards Zo, Ovid Vere’s mentally impaired little sister. He repeatedly manifests his kindness by tickling and pinching her neck and her “Cervical Plexus”, even though he considers the young girl as an excellent subject for his medical experiments. Again, emphasis is laid on a female character that is associated with a condition of animality: not only does her name suggest the phonological resemblance to bestiality, but the young girl also behaves in a manner that reflects that of a beast. Zo’s actions are animal-like: when she is touched on her spine she wriggles and screams, and when she takes her father’s hand, she “[rubs] her head against it like a cat” (65). Quite surprisingly, however, Doctor Benjulia’s complex and ambiguous nature is fully revealed only through his relationship with the girl. In Collins’ view, Benjulia is not simply the “scientific savage” (214), the man who hates dogs because they bark; the one who abhors noise, who doesn’t care about gardens and trees; who eats on his dreadful table of experiments and has bloodstains on his hand and stick that silently tell “their tale of torture” (185). He is also a man who feels sympathy and tenderness for a retarded child who destabilises his asserted cynicism, while looking for his attentions: It was only the hand of a child – an idle, quaint, perverse child – but it touched, ignorantly touched, the one tender place in his nature, unprofaned by the infernal cruelties which made his life acceptable to him; the one tender place, hidden so deep from the man himself, that even his farreaching intellect groped in vain to find it out. There, nevertheless, was the feeling which drew him to Zo, contending successfully with his medical interest in a case of nervous derangement (246).

Furthermore, in order to underline Dr. Benjulia’s humane qualities and allow the reader to feel for him, Collins makes him suffer from excruciating gout, whose acute attacks afflicted the Victorian writer himself during his entire life. The “tortured gouty foot” (95) exasperates the already disturbed personality of the physician who discloses himself at the same time as a monstrous and pathetic figure: “Rage and pain glared in his gloomy gray eyes, and shook his clenched fists, resting on the arms of an easy chair. […] By way of further relief to the pain, he swore ferociously; addressing his oaths to himself in thunderous undertones which made the glasses ring in the sideboard” (130). Even the physical

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description of Dr. Benjulia testifies to the repulsive and pitiful appearance of the physician, who “was almost tall enough to be shown as a giant; […] so miserably […] thin that his enemies spoke of him as ‘the living skeleton’. His massive forehead, his great gloomy gray eyes, his protuberant cheek-bones, overhung a fleshless lower face […] His straight black hair hung as gracelessly on either side of his hollow face”. The dual representation of the physician demonstrates Collins’ efforts to define the crisis of value systems provoked by science, to discuss the alleged inhumanity of vivisectionists, and envision the devastating consequences of the misuse of science itself. The insistence on disabled or mentally disturbed characters that populate most of his novels allows the Victorian writer to challenge the categories of normalcy and sanity and the reliability of established models of health. In a society that shapes its own values upon the equation of psycho-physic integrity and moral rectitude, as well as science and truth, Collins almost perversely deploys the paradigm of medical science to reverse such categories and introduce physicians who are clearly affected by a disturbance. Whereas Dr. Benjulia is devoured by his medical studies, an obsession that deranges him, Ovid Vere suffers from nervous exhaustion, and is compelled to leave England in order to recover from a period of stress. The day on which he confesses his love to Carmina in the Zoological Gardens allows the narrator to point out that: […] his shattered nerves unmanned him, at the moment of all others when it was his interest to speak too freely […] A deadly sense of weakness was beginning to overpower him […] Physically and mentally he had no energy left […] Heavy drops of perspiration stood on his forehead; his face faded to gray and ghastly whiteness – he staggered […] With all her little strength she tried to hold him up. Her utmost effort only availed to drag him to the grass plot by their side. (108-109)

Almost subverting the common romantic cliché, Ovid’s swooning in the arms of his beloved testifies to his psychological weakness and incapacity to come to terms with a world made of cruelty, disputable morality and heartlessness. And even when he finally succeeds in curing Carmina’s hysterical disorder, he does it “more with devoted attention than with a vague new deus ex machina cure” (Wagner 2002, 494), and by employing the medical discovery of a doctor he had met in Canada. Even Mrs. Gallilee, whose amateur interest in science conceals her desire to use it as a solution to the failure of her social ambitions, is psychologically disturbed, and prey to compulsive and morbid behaviour. Thus, moral strength seems to be at odds with the physical integrity or the mental

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stability of the scientists, while weakness becomes the only way to interpret medical science and its potential deceits. Notwithstanding the novel’s conventional happy ending and the apparent resolution of every problem it has posed (the “punishment” of the villain, the “victory” of the good physician Ovid Vere, not to mention the realization of Mrs. Gallilee’s ambition to diffuse scientific knowledge through yet more dinner parties), Wilkie Collins deploys Heart and Science to unveil the potential deceptions of scientific experimentation and its subversive sides. Thus, in emphasising the ethical obligations of science, Collins’ sensational novel inevitably challenges the powerful and compelling myth of medical discourse in the second half of the nineteenth century. Like any other immoderate passion, experimental medicine can undermine human standards of morality insofar as its seductive appeal becomes the source of inhumane consequences.13 The essence of science is thus captured in the indeterminacy of its results, in the tension between sympathy and condemnation that its representatives evoke, and in the destabilising outcomes it may produce on the mysterious, and still unexplored territory of the human mind.

References Baker, William and Clarke, William M. (eds.) 1999. The Letters of Wilkie Collins. Volume 2: 1866-1889. London: Macmillan. Barthes, Roland. 2010. Roland Barthes by Roland Barthes. New York: Farrar, Straus and Giroux. Carroll, Lewis. 1988. “Some Popular Fallacies about Vivisection.” In Alexander Woollcott (ed.), The Complete Works of Lewis Carroll. Harmondsworth: Penguin. Cvetkovich, Anne. 1992. Mixed Feelings. Feminism, Mass Culture and Victorian Sensationalism. New Brunswick, New Jersey: Rutgers University Press. Darwin, Charles. 1958. Selected Letters on Evolution and Origin of Species, edited by Frances Darwin. Mineola, New York: Dover Publications. —. 1999. The Expression of Emotions in Man and Animals. London: Fontana Press.

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On the role of science and its relationships to the nature of human life, see the work of Paul Feyerabend, which refers to the tyranny of Western science and its concomitant, the dehumanization of the human (Feyerabend 2015).

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Dewitt, Anne. 2013. Moral Authority, Men of Science and the Victorian Novel. Cambridge: Cambridge University Press. Ellis, Heather. 2017. Masculinity and Science in Britain, 1831-1918. London: Palgrave Macmillan. Feyerabend, Paul. 2015. The Tyranny of Science. Malden, USA: Polity Press. Greimas Algirdas Julien and Fontanille, Jacques. 1993. The Semiotics of Passions: from States of Affairs to States of Feelings. Minneapolis: University of Minnesota Press. Hardy, Thomas. 2009. The Woodlanders, edited by Dale Kramer. Oxford: Oxford University Press. Obenchain, Theodore, G. 2012. The Victorian Vivisection Debate. Jefferson, North Carolina: McFarland Publishers. Otis, Laura. 2007. “Howled out of the Country: Wilkie Collins and H. G. Wells Retry David Ferrier.” In Anne Stiles (ed.), Neurology and Literature, 1860-1920. Houndmills, Basingstoke and New York: Palgrave Macmillan. Ruskin, John. 1904. The Eagle’s Nest. London: George Allen. Sontag Susan. 2004. Regarding the Pain of Others. London: Penguin. Sparks, Tabitha. 2009. The Doctor in the Victorian Novel. Family Practices. Farnham, Surrey: Ashgate. Wagner, Tamara S. 2002. “'Overpowering Vitality': Nostalgia and Men of Sensibility in the Fiction of Wilkie Collins.” Modern Language Quarterly 63: 4. Wood, Jane. 2001. Passion and Pathology in Victorian Fiction. Oxford: Oxford University Press.



CHAPTER TWELVE “[T]HE DARKER SIDE” OF MEDICINE: THE VICTORIAN NOVEL AND THE “SCIENTIZATION” OF THE MEDICAL PROFESSIONAL ADRIAN TAIT

Introduction In The Doctor in the Victorian Novel, Tabitha Sparks discusses Arthur Conan Doyle’s “little known collection of medical stories, Round the Red Lamp” (Sparks 2009, 158), which she reads primarily for the way in which the stories “perfectly encapsulate” the profound connection between “the formal demise of the marriage plot and the scientization of the doctor” (158). However, Doyle’s belief that it was essential he paint “the darker side” of medical life did not simply encompass doomed romance and failures in love (Doyle 1894, v). Rather, his short stories relate to broader concerns about the medical consequences of “scientization,” and the fear that science brought with it a mastery that misshaped those who possessed it. As this chapter discusses, these concerns emerge in a succession of Victorian narratives, from the relatively well known, such as Wilkie Collins’ Heart and Science, to the now more-or-less forgotten, such as Leonard Graham’s The Professor’s Wife, and Edward Berdoe’s St. Bernard’s: The Romance of a Medical Student.1 These narratives pose profound questions about the impact of new knowledge and new methodologies on the doctor-patient relationship, but also on doctors themselves, some of whom lose more than the human touch: they lose their own humanity. As this chapter therefore argues, the anxieties that

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Sparks, for example, has a paragraph on Berdoe’s novel (2009, 114), but nothing on Graham’s.

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surface in these stories speak to what Roy Porter called “the dialectics of medicine and mentalities” (1997, 4). The nature of that dialectic is, however, a complex, and sometimes problematic one. Narratives such as these provide an “imaginative look at the creativity, complications and consequences of scientific progress” (Stockstill 2016, 125). They sometimes also offer a distorted picture of a highly diverse field of medical endeavour. As Louise Penner and Tabitha Sparks caution, scientization may emerge as “the master plot of Victorian medicine, with a gap between the specialist practitioners and the nonspecialist public functioning as its operative challenge and metaphor” (Penner and Sparks 2016, 1). However, the scientific community was not a “monolith,” and medical progress was by no means uniform or even (Penner and Sparks, 2). Consequently, these narratives do not offer an objective commentary on medical developments, but as Penner and Sparks also observe, they do “tell us what such measures meant to Victorian society and how they were integrated into social politics” (Penner and Sparks 2016, 8). In this sense, these literary responses are themselves “foundational” (Penner and Sparks 2016, 8): they both reflect contemporary understandings of what constituted medicine, and mediate those understandings, with a sometime significant impact on the way in which the public accepted or resisted the emergence of modern medicine; the vexed question of vivisection is a case in point. As such, these narratives form an important but still relatively neglected part of the cultural history of the medical humanities. The aim of this chapter is, therefore, to trace some of the myriad ways in which literary texts from the Victorian period interacted with medical discourse and responded to medical discoveries. As historians of Western medicine have emphasised, the nineteenth century witnessed a significant, even seismic shift in the nature of primary care, as doctors and patients confusedly sought “to come to grips with the ever-changing realities of medicine imposed on them by science, on the one hand, and by subjective views of ‘medical correctness’ on the other” (Shorter 2006, 103). At the beginning of the Victorian period, however, primary care “remained chiefly in the hands of private practitioners” (Porter 2003, 84), each competing with the other for the custom of patients. It was sometimes a problematic model: where competition was lacking, a doctor was free to pursue his own, idiosyncratic idea of what constituted a cure, without fear of contradiction; where competition did exist, the patient’s own idea of what constituted “good medicine” (Shorter 2006, 104) could itself exert an undue influence over the kind of care a

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doctor would provide. As Dr. Burrows drolly remarks, in Arthur Machen’s The Hill of Dreams, “I have my living to make here, you know” (Machen 2018, 166). At its best, however, this kind of longstanding and often intimate relationship between a patient and his or her doctor could be a profoundly important one. It paid for doctors to be kind, and to listen to their patient’s complaints; often without recognising it, private practitioners built up a case history that could itself contribute the correct diagnosis of a complaint. Over the course of the Victorian period, however, “[t]wo things were killing off this old-style family doctor – a shift in the locus of medical practice away from general practitioner to specialist, and a shift in the physical site of primary care from the patient’s home to the doctor’s surgery and the hospital outpatient department” (Shorter 2006, 126). The changes were in large part driven by the “scientization” to which Spark refers (2009, 158). For example, “the infusion of science into medicine” (Shorter 2006, 103) resulted in a “panoply of new technology,” which patients themselves found “reassuring” (Shorter 2006, 120). But whilst patients often had an “implicit confidence in the wonders of progress” (Shorter 2006, 126), scientization also had more disturbing consequences. As medical care became more rigorous and disciplined, “scientifically trained practitioners” increasingly realised that they “could do relatively little to cure disease” (Shorter 2006, 121): “the real function of medicine,” many concluded, “was to accumulate scientific information about the human body” (Shorter, 121). This was the doctrine of “therapeutic nihilism” (Shorter 2006, 121-122). Family doctors, however, were not convinced. Instinctively, they rejected the helplessness that the new doctrine implied, believing (quite rightly) that “an understanding and sympathetic manner […] was in and of itself therapeutic” (Shorter 2006, 123). This was the origin of the “patientas-a-person movement” (Shorter 2006, 123), which emerged in the 1880s as a way of returning the focus to the patient, rather than concentrating solely on the disease. In turn, some questioned whether modern, scientifically-minded practitioners were more interested in advancing medical knowledge than in caring for the sick and injured; it even seemed possible than medicine was losing its moral bearings, particularly when, in the 1870s, instances of the cruelty of vivisection “made headline news” (Porter 2006, 162). Novelists were not slow to reflect these shifting perceptions and sometimes acrimonious debates. Conan Doyle’s short stories are a case in point. Round the Red Lamp opens with “Behind the Times” (Doyle 1894, 1-8), a story that gently but wryly highlights the difference between the

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modern man of medicine, and the more traditional, family doctor that he had all but replaced. As two new doctors install themselves in the country, they find that they are rivals, not with each other, but with the venerable Dr. James Winter. “[A] survival of the previous generation” (Doyle 1894, 4), Winter’s views on the medical profession “are even more reactionary than his politics” (4); to him, “the advance of modern science” is a “huge and rather ludicrous experiment” (4). Yet the sick still turn to him for care. As his “up-to-date” rivals realise (Doyle 1894, 7), Winter “has the healing touch […] His mere presence leaves the patient with more hopefulness and vitality” (6). When the two new doctors fall ill, each secretly calls on Winter, and not on each other, for help (Doyle 1894, 8). What Winter provides – and his modern counterparts do not – is kindness, attentiveness, and compassion, a quality of “psychological support” (Shorter 2006, 123) that was perhaps lost in the advance of scientific medicine. As earlier novels suggest, these qualities were once considered characteristic of the medical practitioner, particularly in the early- and mid-Victorian periods. This is the world described in Anthony Trollope’s Barsetshire novels, and most notably in Dr. Thorne, third in the series. Published in 1858, Trollope’s novel is amongst his most famous; its central figure, Dr. Thorne, is typical of the kind of country practitioner who “settled for life” in a village or county town (Trollope 1988, 31), and whose reputation depended as much on his bedside manner as his medical expertise. As the narrative notes, “[i]t was something in his favour that he understood his business” (Trollope 1988, 35), but it is no means everything; it is only when his trusting, honest nature and “almost womanly tenderness” have been “learned, and understood, and appreciated” that “the doctor was acknowledged to be adequate to his profession” (Trollope 1988, 37). Mary Elizabeth Braddon’s The Doctor’s Wife offers a similarly nuanced understanding of the life and work of a country practitioner in mid-Victorian Britain (although serialised in 1861, the novel is set in the early 1850s). The Wife of the novel’s title is Isabel, a dreamy young woman whose only education has been romantic poetry and prose (Braddon 2008, 27). The Doctor whom she marries is a country surgeon named George. Equally young and naive, George has survived the “fiery ordeal of two year’s student-life at St. Bartholomew’s [where doctors were trained] … almost as innocent as a girl” (Braddon 2008, 6), and returned to take up his father’s practice in the sleepy “Midlandshire” (5) town of Graybridge. Quite without ambition, he devotes himself to his patients and to the poor, and is soon “the best-beloved” (Braddon 2008, 52) man in the area. Only his love for Isabel unsettles his quiet but dutiful life. Once

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married, however, he falls back into his usual routine, unaware that Isabel dreams of much greater things, and he dies of “typhoid fever” (Braddon 2008, 310) contracted whilst working amongst the poor. As the narrator declares (Braddon 2008, 310-311), “how small an account we set upon the quiet courage of the village doctor, who meets death face to face every day, and never shirks the dangerous encounter!” Like Doyle’s Dr. Winter and Trollope’s Dr. Thorne, the figure whom Braddon sought to depict was typical of the best of a generation of medical professionals whose lack of clinical expertise – and often, their personal idiosyncrasies – were mitigated by their sympathetic understanding. “[H]is kindly face seemed to bring comfort,” notes Braddon’s narrative: “[h]e took an atmosphere of youth and hope and brave endurance with him every where [sic], which was more invigorating than the medicines he prescribed” (Braddon 2008, 52). Braddon is not, however, entirely uncritical of her fictional creation. George, notes the narrative, “took his life as he found it, and had no wish to make it better” (Braddon 2008, 7), perhaps implying that, for all his desire to improve the lives of his patients, he lacks the ambition and the imagination to make a decisive difference. It is this lack of ambition – this lack of vision – that Isabel finds so crushing. By the time that Braddon came to write her novel, however, figures such as George were already beginning to seem anachronistic. Medicine was changing, driven by a heroic age of scientific discovery. The very thing that George lacks – imagination – was itself the key. As the astronomer Richard Antony Proctor wrote in 1880 of “our Galileos, Keplers, and Newtons, our Priestleys, Faradays, and Tyndalls, … their best scientific work has owed as much to their imagination as to their reasoning and perceptive faculties” (Proctor 1880, v). For the new generation of scientists, science itself aspired to the quality of poetry: “[t]he philosophy of physical science is a grand epic, the record of natural science a great didactic poem” wrote Robert Hunt, one of the great practitioners and popularisers of the age (Hunt 1849b, 401). Even as the new science was in the ascendant, however, it was beset by “conflicting views” (Hunt 1849a, v). On the one hand, wrote Hunt, there are “the mystical dreams of visionary thinkers” (Hunt 1849a, v) and “the dangerous influences of false modes of reasoning” (vi); on the other, “the utilitarian tendencies of the age … coldly repulsive to the young and imaginative mind” (v). It was, he wrote, a “contest between the False – seductive by its poetic associations, – and the True, as estimated by the standard of the merely useful” (Hunt 1849a, v–vi). This is, in part, the conflict that Braddon dramatised in The Doctor’s Wife, a human tragedy that turns on the opposition between Isabel’s dangerous absorption in

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poetic dreams, and her inability to distinguish “the False” from “the True,” and George’s prosy reliance on the useful. But what might therefore follow if “the mystical dreams of visionary thinkers” (Hunt 1849a, v) were themselves corrupted by “the dangerous influences of false modes of reasoning” (vi)? One such “false mode” becomes the subject of The Egoist, published in 1879, in which George Meredith probed the egotistical but deeply human desire to contain and control nature and the natural. In his “devoted pursuit” (Meredith 1992, 22) of “science,” Sir Willoughby Patterne takes as its corollary a “Nature” that may be safely ordered, managed, and, like his putative wife-to-be, Clara, domesticated. Another such “false mode” is captured in Heart and Science, Wilkie Collins’ “story of the Present Time,” serialised in 1882–3. Here, the character of Mrs. Gallilee becomes so preoccupied with the science she sets out to promote that she is, in the end, entirely consumed by her obsession, to the complete exclusion of all her family ties. And whilst Meredith avoids the suggestion that Patterne has been affected by his interest in science – although he “spoke of little else” (Meredith 1992, 22), his egoism is all his own – Collins implies that science itself might be the corrupting influence, that it should be treated with the utmost caution, and even that science brings with it a mastery that misshapes those who bring it to bear in their work. Collins’ concerns were already apparent in work such as The Woman in White (1860), the novel that made his name as a sensation author. When Marian Halcombe falls ill with typhoid fever, she is attended by a “respectable elderly man,” “well known, all around the country” (Collins 2003, 358), and in character not unlike Trollope’s Dr. Thorne. However, he also lives “at some distance … from gigantic centres of scientific activity” such as London (Collins 2003, 362), and although he is wellintentioned and his focus is patient-centred, his treatment is of dubious benefit. It is Count Fosco, with his “luminous experience of the more subtle resources which medical … science have placed at the disposal of mankind” (Collins 2003, 337), who suggests up-to-date remedies (362); but Count Fosco, for all that he admires the “magnificent Marian” (336), is the villain of the piece. His expertise is in no way correlated with his moral worth; the question, as Collins intimated, is whether Fosco’s kind of expertise – this command of nature and of natural processes – might simply tend to magnify man’s anthropocentric grand-arrogance, and detach him from his humanity. In the case of medical science, these concerns emerged most forcefully in the contemporary controversy surrounding the practice of vivisection. “Far from science being intrinsically benign,” notes G. R. Searle, “many

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self-professed humanitarians saw much in its practice which was barbarically cruel” (2004, 638). Vivisection attracted “noisy public hostility,” and “[v]igorous campaigning” resulted in the Cruelty to Animals Act in 1876, a piece of legislation that no other country matched “before the twentieth century” (Porter 2003, 84). Heart and Science was itself a product of this debate, famous as an instance of Collins’s later, and more socially engaged work. Alongside its portrayal of Mrs. Gallilee, the scientific devotee, the novel offers three, markedly different portrayals of the modern medical professional. The best of the medical profession is embodied in the character of Ovid Vere; his dangerous obverse is the vivisectionist, Benjulia; both are set against the thoroughly ineffectual figure of Mr. Null. Yet even the novel’s portrayal of Ovid Vere implies a criticism of the profession. “[D]evoted heart and soul to his profession” (Collins 1996, 45), he nevertheless works himself to the point of collapse, finding for his condition no solution but a complete break from his work, and travel abroad. Null, by contrast, is simply stupid, but his stupidity is itself culpable; by failing to act on the progressive deterioration of Carmina’s condition, he allows Benjulia to insinuate himself into her care without ever questioning Benjulia’s motives. From the outset, Benjulia recognises Carmina’s condition, but also the uselessness of Null’s prescription. Since her condition is so fascinating, a further deterioration in her health is exactly the outcome he desires. His experience … had satisfied him that stupid Mr. Null’s course of action could be trusted to let the instructive progress of the malady proceed. Mr. Null would treat the symptoms in perfect good faith – without a suspicion of the nervous hysteria which, in such a constitution as Carmina’s, threatened to establish itself, in course of time … (Collins 1996, 255)

In Benjulia’s eyes, his motives are “not only excused, but ennobled, by their scientific connection with the interests of Medical Research” (Collins 1996, 255). As her condition worsens, Benjulia congratulates himself for sacrificing time “in the laboratory” to wait on her: “Carmina was destined to receive unknown honour: she was to take her place, along with the other animals, in his note-book of experiments” (Collins 1996, 280). The question which Carmina’s nurse asks of Null is very much to the point. Is Benjulia “‘a great doctor?’” she asks: the “‘greatest we have,’” replies Null (Collins 1996, 281). But is “‘he a good man?’” the nurse enquires (Collins 1996, 281). Benjulia’s lack of morality is underlined when the returning Ovid realises that Benjulia has “approved of [Null’s] ignorant treatment … for some vile end of [his] own” (Collins 1996, 306). For Benjulia, his motive is honest enough, because the pursuit of

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knowledge is an end – “an excellent end” – and one that justifies any means (Collins 1996, 307). When Ovid declares that Benjulia is a “merciless villain,” Benjulia is, therefore, “completely stupefied” (Collins 1996, 307). Ovid’s comments have no meaning for him. But why? The practice of vivisection is, Collins implies, the real reason for Benjulia’s moral obliquity. In defiance of the new legislation, Benjulia continues to experiment on live animals in his locked laboratory. The question which Collins asks is not, however, whether the pursuit of knowledge is sufficient to justify cruelty to animals; in his mind, that question answered itself. As he explained in a letter to the antivivisectionist Frances Power Cobbe, his concern in writing Heart and Science was to “leave the detestable cruelties of the laboratory to be merely inferred;” he was more interested in tracing “the moral influence of those cruelties on the nature of the man who practices them” (Collins 1996, 370). That influence is made clear in a climactic scene when Benjulia, confronted by his brother, explains the reasons for his pursuit of “the grandest medical discovery of this century” (Collins 1996, 190): Am I working myself into my grave, in the medical interests of humanity? That for humanity! I am working for my own satisfaction – for my own pride – for my own unutterable pleasure in beating other men – for the fame that will keep my name living hundreds of years hence. Humanity! … Knowledge for its own sake, is the one god I worship. (Collins 1996, 190)

Pride and vanity drive Benjulia, but so does the pursuit of knowledge; and knowledge “sanctifies cruelty” (Collins 1996, 190). Yet Collins’ portrayal of Benjulia is by no means a crude caricature. Collins sought to make him “an object of compassion as well as of horror” (Collins 1996, 370). Whilst Benjulia is determined to pursue the cause of medical advancement by any means, vivisection included, he is not inured to the cruelty of his actions. “My last experiments on a monkey horrified me,” declares Benjulia. “His cries of suffering, his gestures of entreaty, were like the cries and gestures of a child” (Collins 1996, 191). Perhaps, Collins implies, the tortured Benjulia is so traumatised by his own actions that he blinds himself to their consequences; perhaps this is why, when confronted by Ovid, Benjulia reacts with “immeasurable astonishment” (Collins 1996, 307). Sacrificing everything to his pursuit of that “grandest” of medical discoveries, Benjulia is, in the end, beaten to a cure by his rival Ovid: “[v]ivisection had been beaten on its field of discovery” (Collins 1996, 324). Benjulia dies by his own hand in his burning laboratory; “[h]is brethren of the torture-table, attended the funeral in large numbers”

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(Collins 1996, 324). Although it is one of the period’s most shocking depictions of misguided medical science, Collins’ Heart and Science is, however, only one of several contemporary narratives that engage with the medical practitioner as vivisectionist. Leonard Graham’s The Professor’s Wife, published slightly earlier (1881) than Heart and Science, is a now forgotten example of this kind of polemical fiction. Like Collins’ novel, Graham’s story depicts one of the new breeds of medical specialist, the physiologist Eric Grant. “The enshrinement of physiology as a high-status experimental discipline was a key feature of nineteenth-century medical science,” notes Porter (2006, 158), and Professor Grant is characteristic of the new drive to use the laboratory (and if necessary, live animals) to extend medical understanding. “We must go forward,” declares Grant (Graham 1881, 54), a man for whom the body is simply “a machine” (57). Like Wilkie Collins, Graham depicts a medical professional who has surrendered his humanity for the sake of knowledge. Cold and unfeeling, Grant is increasingly willing to take any step to advance his cause, and his marriage to the young Beatrice provides him with an unexpected opportunity to do so. Warned that her husband is an “arch-vivisector” (1881, 107), Beatrice ventures into his laboratory, and sees that “something was lying extended and fastened down” on the table before her husband: ‘Eric!’ she shrieked. ‘What is that?’ He flung down his instrument, and strode across towards her. ‘Beatrice! how came you there?’ Her only answer was a ringing scream, and she fell at his feet in strong convulsions. All day, and all the next, Beatrice lay in her darkened room; the least sound or movement near her seeming to fall like torture upon her weakened brain and shattered nerves … (1881, 141-142)

Beatrice is suffering from “some obscure disease of the brain” (1881, 144), but her experience in the laboratory has been so traumatic that it has precipitated her lapse into a catatonic state. The prognosis is a hopeless one. This fact established, Grant coolly takes advantage of Beatrice’s condition to extend his research, reasoning that, “[a]fter all, the lower animals are unsatisfactory; you learn far more by the human subject” (Graham 1881, 156). “[T]he phenomena were most instructive,” he observes after her death (Graham 1881, 156). “You own no law, human or divine, where science is concerned,” Grant’s colleague tells him (1881, 157). Moreover, Grant’s worship of science has left his humanity “stunted and starved” (1881, 156); he has become “positively inhuman” (1881,

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156). Like Benjulia, who sees in Carmina’s condition an opportunity to advance medical research, Grant exploits Beatrice’s state for his own ends. For conventionally-minded contemporaries, this was doubly appalling: in well-to-do Victorian Britain, women were considered the Angels of hearth and home, to be venerated and adored, but also valued as a “voice of conscience” (Searle 2004, 55). Grant, however, ignores his wife, treats her as foolish and sentimental, and classes her with all the other nonprofessionals who “can’t understand” his reasons (1881, 150). Graham’s novel was not intended simply to shock its readers, but to convert them: the text includes eight pages of notes (159–167) – including excerpts from official government “Blue Books” – that substantiate its antivivisection argument. Contemporary critics were not necessarily convinced. “It is difficult to say how far stories written to illustrate the moral evil of particular practices answer their purpose,” wrote The Spectator: That this story, which is not without power, does draw an alarming and a not unjust picture of that hardening of the heart which comes of asserting the right and cultivating the habit of inflicting pain deliberately on our fellow-creatures, in order to add to the knowledge of vital laws, cannot be denied. The real question, however, is whether … exaggeration and overpainting … may not do more to stimulate sympathy with the wrong side than to enlist sympathy with the right. (The Spectator, 1881)

But as The Spectator also conceded, mindful of the “revolting annals of Continental or American vivisection,” “there is hardly one touch in [Graham’s novel] which might not be fairly justified as belonging to the ideal of the same general school of morality towards which the teaching of the vivisectionists, that any amount of pain may be inflicted on sensitive beings for sufficient scientific ends, obviously tends” (The Spectator, 1881). If, therefore, there was as yet “no such monster as Sir Eric Grant” (The Spectator, 1881), it was clearly a possibility; so where might such degraded and degrading practices lead? What might be the outcome of “the teaching of the vivisectionists,” when they so plainly led to such cruelty and cynicism, and such a frank disregard for consequences? Late-century writers suggested answers, whilst simultaneously reconceptualising their narratives in terms of the Gothic, scientific romance, or the occult. In R. L. Stevenson’s The Strange Case of Dr. Jekyll and Mr. Hyde, published in 1886, the outwardly respectable Jekyll experiments with a new kind of serum that will enable him to mutate into an entirely different, distorted version of himself, thereby allowing him to indulge in all his vices, whilst abrogating any responsibility for them. If

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each side of his personality “could but be housed in separate identities,” Jekyll reasons, “life would be relieved of all that was unbearable; the unjust might go his way, delivered from the aspirations and remorse of his more upright twin” (Stevenson 2003, 56). Once again, it is the stunning success of “scientific discoveries” (Stevenson 2003, 56) that makes this apparently miraculous process possible, and to readers, plausible. “[T]he transformation of Dr. Jekyll reads dangerously like an experiment out of The Lancet,” observes Vivian, in Oscar Wilde’s “The Decay of Lying” (Wilde 2010, 8). Nor was Stevenson the only writer to extrapolate horror from the apparently careless advance of medical science. H. G. Wells was the author of some of the most enthusiastic prophecies of a technocratic future, including Anticipations (1901) and A Modern Utopia (1905), but he was also capable of writing deeply disturbing predictions of a future gone awry. In The Island of Dr. Moreau, published in 1896, Wells’ narrator, Prendick, is washed up on an island where he discovers what he first mistakes for “Beast Men” (Wells 2005, 66), perhaps fashioned as Hyde was. “‘They were men,’” Prendick accuses Moreau and Montgomery, “‘men like yourselves, whom you have infected with some bestial taint’” (Wells 2005, 66). The reality is no less chilling. Moreau has devoted his life “to the study of the plasticity of living forms” (Wells 2005, 71), creating new kinds of monsters from animals. “The creatures I had seen were not men, had never been men,” Prendick realises (Wells 2005, 70–71). “They were animals – humanized animals – triumphs of vivisection” (Wells 2005, 71). Yet Moreau is untroubled by the pain he has inflicted. “‘A mind truly opened to what science has to teach must see that it is a little thing,’” Moreau tells Prendick (Wells 2005, 74). As Sparks points out, Arthur Machen also wrote stories that reflect on the “drive to knowledge – unchecked by cautionary compassion or empathy for patients” (Sparks 2009, 112). The medical practitioners in both “The Inmost Light” and “The Great God Pan,” published in 1894, are prepared to take any step to advance their understanding, even if it is at the expense of those whom they are supposed to love, or for whom they are meant to care. In “The Inmost Light,” Dr. Black is so obsessed with his pursuit of “occult science” (Machen 2011, 25) that he experiments on his wife, knowing that the experiment will annihilate her. By extracting from her “that essence that men call the soul” (Machen 2011, 27) – the “flaming inmost light” that gives the story its title – Black creates a monster with “the visage of a satyr” (Machen 2011, 6). Black expects no less, yet he has pressed on with his experiment in spite of the entreaties of the woman whom he claims to love. Nevertheless, Black is devastated by the

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experience (Machen 2011, 17). In “The Great God Pan,” Dr. Raymond – a self-styled expert in “transcendental medicine” (Machen 2018, 43) – carries out an experiment intended to collapse the boundary separating the spirit world from the material one. To do so, however, requires him to carry out brain surgery on the young woman for whom he has cared since he rescued her “from the gutter” as a child (Machen 2018, 46). For Raymond, that act of altruism is sufficient to justify his actions: “her life is mine, to use as I see fit” (Machen 2018, 46). As Machen’s elaborate story unfolds, it becomes clear that Raymond has succeeded not only in destroying the girl’s sanity (Machen 2018, 50), but unleashing a monster. Raymond himself is quite unmoved, bearing out Moreau’s remark, in Wells’ tale, that “‘[t]he study of Nature makes a man at last as remorseless as Nature’” (Wells 2005, 75). In “The Case of Lady Sannox” (Doyle 1894, 156–173), another of the stories in Round the Red Lamp, Doyle himself makes play with a similar notion. In this, “the most violent story in the collection,” another medical practitioner allows his “insatiable medical curiosity” to get the better of his principles (Sparks 2009, 159). Invited to carry out surgery on a mysterious woman, Douglas Stone realises too late that the person on whom he has operated – and whom he has been tricked into disfiguring – is none other than his mistress, Lady Sannox. He has fallen victim to the “vengeful” plot of her husband (Sparks 2009, 159). Lady Sannox retreats from society. Stone suffers a fate not unlike the one that befalls Beatrice, in The Professor’s Wife: he loses his mind (Doyle 1894, 156–7). Another of Doyle’s tales, “A Physiologist’s Wife” (Doyle 1894, 120– 155), provides a comic contrast to this grisly story. Professor Ainslie Grey is “the very type and embodiment of all that was best in modern science” (Doyle 1894, 122), but as the narrative faithfully records, Grey also keeps a terra-cotta bust of Claude Bernard in his dining-room. Bernard is one of those “Continental” vivisectors to whom The Spectator alluded, and whom Graham cites in evidence (Graham 1881, 162–4) against the “torture of sentient beings” (Graham, 151); Grey is clearly a fan. Unimaginative and apparently unemotional, Grey is convinced that the “male type” is “the superior” (Doyle 1894, 123). Nonetheless, he decides to “submit to the common lot of humanity” (Doyle 1894, 125), and marry. It transpires that his new wife is a bigamist. Her secret revealed, she abandons him, reasoning that “he has not heart” (Doyle 1894, 149). To the contrary, his heart is broken, and he slowly dies of it, a process he finds of “great interest” (Doyle 1894, 154). Amusing as his reaction may be, readers may well have concluded that the Professor’s fate is merited, if not because of his apparent acceptance of vivisection, then because of the emotional

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sterility he seems to cultivate with such dedication. In Sarah Grand’s The Beth Book, published in 1899, the connection is made explicit: the eponymous Beth leaves her husband when she discovers that he is a vivisector. His “cruelty to animals is proof of his unfitness as a husband,” notes Sparks; Beth explains to him “that she ‘cannot understand any but unsexed women associating with vivisectors’” (Sparks 2009, 114). Vivisection continued to attract “strong, organised protests right up until 1914” (Searle 2004, 638). There was, however, a broader but equally significant concern amongst the members of a lay public that recognised the growing gulf between the patient and the now expert medical practitioner: how could the patient be sure that the medical professional had his or her own best interests at heart? If medical professionals saw vivisection as a price worth paying to advance the cause of medical science, could patients be sure that a treatment was intended simply as a cure for their condition? What other abuses might the medical experts be concealing? In St. Bernard’s, The Romance of a Medical Student, published in 1887, Edward Berdoe supplied a dismaying answer. Berdoe was at once a physician, active antivivisectionist, literary critic, and writer; he insisted that literature and poetry “were the only antidote” to the conscience-deadening effect of science, and considered that it was essential the “man of science” recover the “imaginative dimension” of his work if he was to retain his humanity (Ettorre 2016, 14). Here, Berdoe’s beliefs echo those of Robert Hunt, who was himself a novelist, poet, and scientist, but Berdoe’s comments were increasingly unusual in the later Victorian period, when science was divesting itself of the poetic emphasis that Hunt, Proctor and others had seen as integral to knowledge production. Moreover, Berdoe made these concerns the basis of a wideranging and unflinching critique not only of the new medical specialist, but also of the growing centralization of primary care. These changes contribute to a dangerous breakdown in the patient-doctor relationship, Berdoe argues, and the establishment of a medical elite – “the true high priests of science” (Berdoe 1888a, 23) – untrammelled by matters of conscience. Published under the pseudonym Æsculapius Scalpel, St. Bernard’s is a polemic, and only secondarily a fictional narrative. The story of the virtuous Harrowby Elsworth and his eventual marriage to Mildred Lee is frequently interrupted by lengthy passages of exposition; the result, Berdoe accepted, was “about 25 per cent romance and 75 per cent stern reality” (Berdoe 1888a, 9). The novel was also widely reviewed and quickly republished, having attracted considerable criticism from both lay periodicals (The Spectator, The Illustrated London News) and specialist publications (such as The Lancet). In turn, this response

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prompted Berdoe to publish a commentary on the novel, entitled Dying Scientifically (1888), in which he systematically justified the points that he had raised in the novel. In hospitals just like “St. Bernard’s,” Berdoe contended, “the healing of patients is deliberately retarded for the purpose of clinical study” (1888a, 7), but also “made subordinate to the professional advantage of the medical staff and the students” (1888a, 7). “New drugs are tried upon hospital patients” (1888a, 7–8), and patients are made to “undergo unnecessary operations and even amputations” (1888a, 8). “[Y]ou cannot even die in peace, but are ever in danger of some ghastly medical freak being tried upon you” (Berdoe 1888a, 8–9). We can detect, in part, the influence of therapeutic nihilism in the way in which patients at the hospital are regarded: “[a]t present, physiology and pathology so entirely occupy the attention of the doctors,” claims the narrative, “that treatment is relegated to the distant future. A French physician spoke the truth when he said, “the object of the scientific practitioner is to make a good diagnosis in life, and then verify it on the post-mortem table’” (Berdoe 1888b, 117). But in Berdoe’s view, the medical fraternity’s fundamental failing lay with a basic lack of Christian compassion. This failing is nowhere more obvious than in the figure of Mr. Malthus Crowe, who is, almost inevitably, a professor of physiology and pathology. Crowe is at the peak of his profession; he is also a vivisector, and “[di]sregard of all pain in others [and] contempt for those who professed to care [were his] distinguishing traits” (Berdoe 1888b, 119). Yet the hospital accommodates Crowe in spite of his “moral character;” as the narrative observes, he is “an author in his branches of science, and accordingly brought much kudos to St. Bernard’s” (Berdoe 1888b, 120). Like Collins’ own, sensational rendering of medical science run awry (and running amok), Berdoe’s novel is nothing if not lurid; Crowe is eventually revealed as a murderer, betrayed by his erstwhile assistant, Mole, for no better reason than that Mole covets Crowe’s chair (Berdoe 1888b, 278). The more important aspect of Berdoe’s novel is, however, its wider critique of hospital management, and the romance between Elsworth and Lee, which leads them to collaborate in a “new hospital scheme” (1888b, 279). Established on humane principles, the Nightingale Hospital attracts “scorn and contempt” (1888b, 282) from the medical establishment; it also sets out to “educate men for the medical profession, … without entailing suffering, shame, or loss on man, woman, or child” (1888b, 282). Berdoe’s work is, therefore, unusual in the breadth of its concerns. Yet it too reproduces a now familiar debate about scientization, and “foul accumulations of scientific error” (1888b, 286). What the novel fails to do

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is challenge a foundational belief in the importance of medicine’s scientific basis; as Berdoe himself wrote in his “key” to St. Bernard’s, “I am entirely orthodox in my practice” (1888a, 12), and could not be claimed as “a brother by any homeopathic, anti-vaccinationist, or hydropathic heretic” (1888a, 12–13). The contemporary (and related) emergence of “alternative medicine” (based, as Porter notes, on a “principled rejection of orthodox medicine”) falls outside Berdoe’s focus (Porter 1997, 389).

Conclusion As public doubts about “unchecked scientific progress” (Stockstill 2016, 126) merged with concerns about the changing nature of primary care, a growing number of Victorian novels and short stories wove medical debates into their narratives. Nevertheless, the scientificallyminded medical practitioner became an increasingly dominant figure. Berdoe’s late-century novel marks the speed with which medical practice had changed. In the mid-century world of fictive Barsetshire, the “oldstyle family doctor” was still pre-eminent; by the time Berdoe wrote his incendiary “romance,” this kind of figure was quickly dying out, as generalists became specialists, and care shifted from the home to the surgery or hospital (Shorter 2006, 126). To those prospective patients “with implicit confidence in the wonders of progress” (Porter 2006, 126), these changes were all for the good, but as a growing number of writers were prepared to argue, in sometimes openly polemical, hybridised texts, these changes came at the expense of what many would have seen as a founding principle of the medical profession: its humanity, rather than its scientific expertise. These doubts crystallised in the contemporary – and “particularly vicious” (Stockstill 2016, 125) – debate about vivisection, a practice uniformly stigmatised by writers as diverse as Wilkie Collins, H. G. Wells, and Arthur Conan Doyle. As Searle points out, however, the vivisection debate also attracted those who were mistrustful of science itself; doctors simply “bore the brunt” (2004, 638). Equally importantly, the vivisection debate tended to shift attention away from more general questions about other aspects of medical practice, such as specialization and centralization, to which Berdoe was unusual in drawing attention. The story these texts present is, therefore, a partial one, with its own in-built bias. In an age that was so caught up in the idea of scientific advances and so certain of the inevitability of progress, these stories and novels nevertheless acted as a kind of counter-balance or corrective, presenting

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narratives of doubt and resistance that remain relevant today, in an age when the transhuman is every day becoming more real.

References Collins, Wilkie. 1996. Heart and Science, edited by Steve Farmer. Plymouth: Broadview. —. 2003. The Woman in White, edited by Matthew Sweet. London: Penguin. Doyle, Arthur Conan. 1894. Round the Red Lamp: Being Facts and Fancies of Medical Life, 2nd edition. London: Methuen. Ettorre, Emanuela. 2016. “‘Disposable bodies’: Edward Berdoe, the Language of Power and the Improbable Religion of Medical Science.” In Corpi, Soglie, e Frontiere, edited by Emanuela Ettorre and Lorrella Martinelli (eds.), 13-25. Lanciano: Carabba. Graham, Leonard. 1881. The Professor’s Wife: A Story. London, Chatto and Windus. Hunt, Robert. 1849a. Panthea, the Spirit of Nature. London: Reeve, Benham, and Reeve. —. 1849b. The Poetry of Science, or, Studies of the Physical Phenomena of Nature, 2nd edition. London: Reeve, Benham, and Reeve. Machen, Arthur. 2018. Decadent and Occult Works, edited by Dennis Denisoff. Cambridge: Modern Humanities Research Association. —. 2011. The White People and Other Weird Stories, edited by S. T. Joshi. London: Penguin. Meredith, George. 1992. The Egoist, edited by Margaret Harris. Oxford: Oxford University Press. Penner, Louise, and Tabitha Sparks (eds.). 2016. “Introduction.” In Louise Penner and Tabitha Sparks (eds.), Victorian Medicine and Popular Culture, 1-8. Pittsburgh, PA: University of Pittsburgh Press. Porter, Roy. 2003. Blood and Guts: A Short History of Medicine. London: Penguin. —. 2006. “Medical Science.” In Roy Porter (ed.), The Cambridge History of Medicine, 136-175. Cambridge: Cambridge University Press. —. 1997. The Greatest Benefit to Mankind: A Medical History of Humanity from Antiquity to the Present. London: HarperCollins. Proctor, Richard Anthony. 1880. The Poetry of Astronomy. London: Wyman & Sons. Scalpel, Æsculapius (Edward Berdoe). 1888a. Dying Scientifically: A Key to St. Bernard’s. London: Swan Sonnenschein, Lowrey & Co.

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—. 1888b. St. Bernard’s: The Romance of a Medical Student. London: Swan Sonnenschein. Searle, G. R. 2004. A New England? Peace and War, 1886-1918. Oxford: Clarendon Press. Shorter, Edward. 2006. “Primary Care.” In Roy Porter (ed.), The Cambridge History of Medicine, 103-135. Cambridge: Cambridge University Press. Sparks, Tabitha. 2009. The Doctor in the Victorian Novel: Family Practices. Farnham: Ashgate. The Spectator, March 19, 1881. Accessed 17 December, 2018. http://archive.spectator.co.uk/article/19th-march-1881/20/theprofessors-wife-it-is-difficult-to-say-how-far. Stevenson, Robert Louis. 2003. The Strange Case of Dr. Jekyll and Mr. Hyde, edited by Robert Mighall. London: Penguin. Stockstill, Ellen J. 2016. “From Vivisection to Gender Reassignment: Imagining the Feminine in The Island of Doctor Moreau.” In Louise Penner and Tabitha Sparks (eds.), Victorian Medicine and Popular Culture, 125-136. Pittsburgh, PA: University of Pittsburgh Press. Wells, H. G. 2005. The Island of Dr. Moreau, edited by Patrick Parrinder. London: Penguin. Wilde, Oscar. 2010. The Decay of Lying and Other Essays. London: Penguin.



CHAPTER THIRTEEN THE MUTE BODY: ILLNESS AND FAMILY CRISIS IN LATE IMPERIAL CHINESE FICTIONAL MEDICAL NARRATIVES YING WANG

It is hard to name a genre in late imperial Chinese literature that can tell us more about the subjective suffering and life experiences of ordinary patients than medical narratives in vernacular fiction. These are tales that represent sickness at the level of subjective experience. Representations of patients’ individual experiences in fictional medical narratives show that sickness is not merely a state of poor health, but also a process that illuminates social identities and interpersonal relationships while exposing fundamental disorders in families and other power structures. The creation and publication of vernacular fiction flourished during the Ming and Qing dynasties (1368-1912). Many candidates who failed imperial examinations became authors of vernacular fiction. The development of the publishing industry and the commodity economy promoted the production of vernacular fiction in cities, especially in the Jiangnan Ụ༡ region, or the area around the Yangzi delta. Whereas classical tales in the Tang Dynasty (618-907) focused on marvellous and strange occurrences, that is, on the extraordinary, Ming-Qing vernacular fiction paid increasing attention to individual emotions and the ordinary lives of common people (D. Chen 2000, 109-110). As a universal experience of everyday life and a deviation from normal good health, sickness has considerable potential to produce strangeness based on readers’ life experiences. Representations of sickness in Ming-Qing fiction also provided a unique perspective from which to understand the subjectivity of patients and their social lives at the time.

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I define the medical narrative in Ming-Qing vernacular fiction as a story in which a character suffers from sickness and its effects on his or her social life. The patient’s experience is the ordering principle of these narratives. For patients, sickness occurs not only in the body, but also in a variety of sites that constitute the patient’s social relationships, which can be understood as a series of concentric circles. The patient’s social life is subverted and reconstructed through the process of sickness. Much of the experience of sickness is related to space. For the purposes of this chapter, I focus on stories based on patients’ subjective experiences within home-centred spaces. The home-centred space is characterised as static and settled, a space where the patient is surrounded by familiar people and objects. As presented in the tales, this home space is structured by some of the ideals and tenets associated with Confucian and ritualist models of the family. To maintain a stable and well-organised family system, a codified system of ritual propriety demands that every family member fulfils the duties prescribed for his or her role. For example, the third-century BC Classic of Rites (Liji⿞䁈) gives a prescriptive vision of family members’ daily behaviour and attitudes: “kindness on the part of the father and filial duty on that of the son; gentleness on the part of the elder brother and obedience on that of the younger; righteousness on the part of the husband and submission on that of the wife; kindness on the part of elders and deference on that of juniors” (Yang 1997, 376). This blueprint of the family system puts the emphasis on morality. However, once sick, a patient may be exiled to the margin of his or her family network. As Talcott Parsons puts it, to be sick is to be socially “deviant” in some way. A deviant person threatens social stability because that person is not playing his or her proper, assigned social role (Burnham 2005, 37-38). It is in the nature of illness that patients fall short not only in duties associated with their social roles, but also in activities of their normal lives and family relationships. The vernacular tales therefore tend to reassert the dictates of body, which are sometimes neglected in the prescriptions of the Confucian classics. In medical narratives about sickness at home, sickness often causes an identity crisis in the patient and affects his or her relationships with other family members, testing bonds between parents and children, between siblings, and between spouses.

Threat and Damage to Marriage A great many fictional medical narratives focus on marital relations, since marriage is a fundamental and key model in the constitution of traditional Chinese family ethics. The three main goals of marriage are to

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offer sacrifices to ancestors, to secure a helpmate, and to produce offspring (P. Chen 1990, 16). The representation of marriage in late imperial fictional narratives is closely related to these goals. If one partner in the couple falls ill, especially through severe and physically unpleasant diseases, these goals are difficult to realise. Thus the patient’s marriage is often threatened or damaged. As early as in Dadai lijiབྷᡤ⿞䁈, composed during the Former Han Dynasty (202 BC-AD 8), “severe repulsive disease” (ejiᜑ⯮) is listed as one of seven justifications for a husband divorcing his wife, “because a wife with severe disease is not able to sacrifice to ancestors” (Wang 1983, 255). When they mention eji, most medical narratives in late imperial vernacular fiction focus on leprosy, for other physical disabilities do not have the same terrible symptoms and contagiousness. Leprosy can disfigure the patient and can also be transmitted to other persons. Moreover, it was difficult to cure at the time. Chen Yan䲣䀰 (1131-1189) described the horrid appearance of the patient with leprosy in the fifteenth volume of his Sanyin jiyi bingzheng fanglunйഐᾥа⯵䅹ᯩ䄆: Leprosy brings about great sores and torments. The sores run with pus. Patients’ eyebrows and beard fall off, and they even lose fingers and toes. They feel great pain and itching. Their facial color seems dry and haggard. Their noses become flat and their eyes putrid. Their teeth are gnawed and lips open. There is no disease more severe than this. Among a hundred persons who suffer it there is not one who can survive” (Y. Chen 1983, 217).

The patient’s appearance is terrible enough to frighten his or her family members. In late imperial fictional medical narratives, the theme of leprosy’s damage to marriages is common. For example, the tenth story of Silent Operas by Li Yu (1610-1680) tells how Han Yiqing’s wife’s leprosy poses a deadly threat to their marriage. Miss Yang was originally an extremely beautiful girl when she married. Unfortunately, she suddenly got leprosy at the age of twenty. Her face, which had been like a flower or jade, immediately swelled up. A delightful lady became a sordid leper. Her husband was afraid to see her and therefore took a concubine, Miss Chen. (Li 2006, 166) Although Han Yiqing does not divorce his wife, their marriage has a mere nominal existence. He is no longer close to her because of her dreadful symptoms, and promptly takes a concubine. Moreover, because there is every likelihood that Miss Yang cannot be cured, she is considered a dying person and loses her status. Miss Chen’s family agrees to the marriage because they believe Yang will die in a short time so that Chen

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will be able to replace her. It is significant that the sickness causes more than merely physical suffering for Miss Yang. More importantly, it completely changes her experience of her marriage and life. As a hopeless patient, she loses her husband’s love and her expectations for the future. Thus, she sincerely treats Chen as her substitute, informing her that Han is a suspicious and stingy husband. He is easily angered when his wife takes money and presents to her parents’ home, or speaks with her male cousin. Yang gives Chen tips on how to avoid incensing Han. These words imply that Yang’s sickness cuts off her experience of time: in her imagination, the future belongs to Han and Chen, but not to her. So she attempts to pass her selfexpectations on to Chen, but when her condition surprisingly takes a favourable turn, so that she suddenly has a future, Chen poisons her food and accidentally cures her. Afterwards Chen designs a series of intrigues using the information Yang has given her about Han’s suspicions and makes Han believe that Yang is stealing his goods and committing adultery with her male cousin. Han almost divorces Yang. In the story, Yang’s marriage is hit by two crises, one caused by sickness and another by Chen’s plotting. The plot is hatched based on Yang’s last words when she was sick. The consequences of the two crises are the same: Han becomes estranged from his wife. In this story, the leper wife’s appearance is a key factor when her marriage suffers substantial damage from sickness. Once her face is disfigured by leprosy, Han is afraid to see her and takes a concubine. He even promises Chen that he will love her more than his wife even if Yang can somehow recover. After Yang is unexpectedly cured, “Han found his wife had resumed her beauty, and naturally loved her as before” (Li 2006, 168). “Naturally” (ziran㠚❦) indicates that Han changes his attitude towards his wife as a result of her beauty. At the end of the story, after Chen is infected by a mangy pig, “her once fine and milky skin became leathery and scaly. Han could not help crying out when he touched her” (168). His love of Chen changes based on her appearance as well. Worth noting is that Chen’s retribution for her plot against Yang starts with her illness and continues with the loss of her husband’s love. She repeats the steps of Yang’s suffering. If this is a fitting punishment of her behaviour, there is no doubt that Han should be partly responsible for this outcome, since the two crises in his marriage are to some degree due to his attitude toward his wife, his suspicion, and his stinginess. However, he can still have no qualms of conscience in appreciating Yang’s beauty and abandoning the disfigured Chen. He seems innocent in the author’s design, suggesting that the way a sickness affects the patient’s marriage is always

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mediated through gender and power dynamics. By contrast, when the patient with eji is a male, although his wife’s parents sometimes hope they will divorce, it is common for the wife to insist on staying with the patient. In late imperial China, it was widely believed that the marriage relationship was formally established at the time of engagement. Thus the principle that a woman should serve only one man was also applied to unmarried couples. In fictional medical narrative, after a man becomes ill, his fiancée often refuses to break off the engagement. That is, when a male patient suffers a repulsive illness, the threat to his marriage is completely different from the female patient’s case: suggestions to divorce or break off the engagement often come from his wife’s family or from the patient himself, while his spouse or fiancée attempts to maintain the marriage relationship. For instance, in the ninth story in Stories to Awaken the World, Duoshou contracts leprosy at fifteen. “The handsome boy now looked like a toad. His skin was like that of an old turtle. His scratching fingers smelled of pus, and his sordid body gave off a foul stench” (Feng 2009, 189). Unfortunately, Duoshou’s condition does not improve for ten years. His fiancée Duofu’s mother learns about Duoshou’s repulsive illness and grumbles tearfully at home to her husband, complaining that the leper will ruin her daughter’s life. However, when Duoshou’s father suggests returning the horoscope card to Duofu’s family so her parents can select another son-in-law, Duofu declines to return the betrothal gifts, saying, “Have you ever seen any good woman taking betrothal gifts from two families? Wealth, poverty, misery or happiness, are all predestined. I am a daughter-in-law of the Chen family while alive and will be a ghost of the Chen family after I die” (193). Duofu’s strong reaction to the broken engagement cannot be explained by her love for Duoshou, given that she does not know Duoshou at all. She insists on the principle that a woman should be engaged to and marry only one man to preserve her chastity. It seems that Duoshou’s sickness is a challenge set by heaven to test her determination. It is noteworthy that this story represents in detail the patient Duoshou’s subjective experience, which constitutes the central plot of the medical narrative. Compared to the earlier classical tale from which this vernacular story was adapted, this story describes how Duoshou’s life experience is affected by his illness. When he was a healthy person, he was extremely handsome and graceful. When Duofu’s father first meets him, he is deeply impressed by his poise, his articulateness, his clear voice, and his correct observance of etiquette, so he agrees to engage his daughter to Duoshou. The story paints him as a model student, implying that he studies hard even through the Double Ninth Festival. If he had not

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contracted leprosy, he would have been sure to pass the imperial examination and become a jinshi䙢༛, the highest degree in this examination. However, the sickness not only disfigured his appearance, but also affected his psychology and his attitude towards life. Throughout his struggle with leprosy, Duoshou becomes fragile and desperate. His familiar life is destroyed, and there is little hope for his future. As he feels neither dead nor alive and is deeply depressed, he repeatedly expresses his despair. After receiving ineffective treatments for several years, he determines to untie the marriage bond because “no medicine has worked so far. It looks like I’ll never get well. Let’s not ruin their daughter’s chances” (194). If Duofu had not insisted on the engagement, he would certainly have given up his hoped-for married life. After marrying Duofu, he sleeps apart from his wife at night, thinking, “I am going to die any day now. The marriage won’t last long. Why soil a virgin?” (200) That is, he considers himself a dying man, always tortured by his anxiety over death and with no hopes for a long marriage life. After four years, he hears that a blind fortune teller has come to his town, and he goes to him to ask when he is going to die. To visit a fortune teller indicates that he feels it is difficult to fathom destiny after ten years of torment from leprosy. Unfortunately, the fortune teller tells him that his last ten-year period, from age fourteen to twenty-three, was particularly unfortunate, but the next period from twenty-four to thirty-three will be even worse. Duoshou loses his last faint hope due to this judgement, and he attempts to commit suicide after going back home. On the one hand, he thinks his illness is desperate, and he is facing death at all times. On the other hand, as a severely sick husband, he feels guilty that his wife has cared for him for three years, since he has no way to reward her. He buys arsenic and takes it with wine, for he considers it the best way to free himself and his wife from this difficult life. Unexpectedly, consuming poison heals Duoshou’s leprosy. The miracle of Duoshou’s recovery conveys the concept of predestination and the power of virtue. It is Duofu and Duoshou’s dedication to each other that turns death into life. It is significant that Duofu believes her husband’s illness is her fate, and all the sufferings they face are predestined. She decides to submit to fate and perform her duty to serve her husband. Duoshou also gives himself over to a kind of virtue, or at least tries to make a virtuous self-sacrifice, and is rewarded for it at last. That is, heaven sets the test of sickness, binds them together, and arranges for a happy ending. Although ordinary people cannot fathom their destiny, they are able to receive their reward after suffering, as long as they conform to heaven’s will and fulfil their obligations.

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Transformation of Family Power A prescriptive model of family responsibility in ancient China holds that the male is in charge of affairs outside the family and the female is responsible for domestic affairs. To perform family rites and harmonise relationships, the female’s role in managing family affairs and maintaining morality is a key factor. According to Dong Kai’s Zhouyi zhuanyi fuluઘ ᱃ۣ㗙䱴䤴, “the way of family relies on the female’s rightness. If the female has moral rightness, the way of family is right…If the female has moral rightness, it is known that the male also has moral rightness” (Dong 1983, 361). Therefore, as long as the female who is responsible for the household performs her role properly, the order of family power works well. In a traditional Chinese family, where many generations live together and share property, the patriarch’s wife serves as the manager of the household. She is responsible for all the servants, cooking, needlework, finance, marriage and funeral ceremonies, and social intercourse with female members of other families. The patriarch’s wife therefore exercises power over all family affairs. When she gets ill and has to find a replacement, the family power is transferred. In fictional medical narratives, sickness that causes the transfer of power is a metaphor for chaos and disorder. The patient’s sick body symbolises the decline of a family, and in some specific situations, the political crisis of a country. In two novels that focus on family life, Linlanxiang ᷇㱝俉 and Hongloumeng ㌵⁃དྷ, the ways in which sickness causes power transformation and the breakdown of family order are fully represented. In Chapter 15 of Linlanxiang, Geng Lang has a wife, Yunping, and four concubines in total: after he gets married, his mother enlists Yunping to manage the household. She is talented and organised, and everything is arranged in perfect order. Unfortunately, in Chapter 31, Yunping contracts an illness and takes to her bed. Then Geng Lang privately gives the account books and keys to his fifth concubine, Caiyun. However, Caiyun abuses her power and performs immoderately in meting out rewards and punishments, and everyone complains about her. Both internal and external households become suspicious of her. Disorder in family affairs produces disastrous effects. As mentioned above, in family narratives, the female’s moral rightness represents the male’s: the fact that Caiyun is not able to manage the household in the right way will have effects upon Geng Lang’s virtue. In the next chapter, Geng Lang follows Caiyun’s suggestion and parts ways with his beneficial friends, and instead stays at home and leads a loose life with Caiyun. He indulges in playing, singing, wine and

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feasting all through the night. At last he is confined to his bed with a serious cold due to excessive wine and sensual pleasures. Geng’s sickness is superficially caused by wine, women, and coldness, but it is a metaphor for disorder in the internal family and deterioration of human relations. The origin of this effect is Yunping’s sickness and the transformation of family power. From Yunping’s sickness to Geng Lang’s sickness, what is demonstrated is the way in which power relationships are reconstructed and how this reconstruction affects both domestic relations and relations with the wider world. These metaphoric meanings of sickness and transformation of family power are expressed even more fully and clearly in Hongloumeng, the greatest novel in Chinese literary history. In Chapters 13 and 55, the novel describes how Wang Xifeng, a woman who is in charge of the household, contracts an illness and how it leads to the transformation of power relationships. In Chapter 13, after Qin Keqing’s death, her mother-in-law Youshi is ill in bed and unable to arrange anything. Because Youshi’s husband Jia Zhen is afraid that the Jia family will be laughed at if any breach of etiquette occurs at a time when many noble families will be paying visits, he invites Xifeng to take charge of Keqing’s funeral ceremony. At the time, Xifeng has just begun managing the Rong Mansion instead of Lady Wang and she is happy to display her administrative ability: “Although she ran the household competently, as she had never been entrusted with grand affairs like weddings or funerals, she was afraid others were not yet fully convinced of her efficiency, and she was longing for a chance like this” (Cao 1999, 348-349). The power transformation caused by Youshi’s sickness provides an opportunity for Xifeng to organise the household. She recognises the defects of customs in the Ning Mansion and formulates a set of strict rules to rectify these drawbacks: for instance, she specifies every servant’s duties and clearly informs them of the punishments if they make mistakes. These rules bring an end to the disorder, negligence, and pilfering of the past. As Keqing’s funeral ceremony approaches, all kinds of issues keep her too busy to eat or take a moment’s rest. Xifeng enjoys her busy and proud career and is in high spirits: “She worked so hard day and night and handled everything so well that not one of the household, high or low, could be but impressed” (371). The narrative dwells on Xifeng’s talent and ambition. It is significant that Youshi’s sickness causes her absence and creates Xifeng’s success, since this transformation of power strengthens Xifeng’s central position in household management; as she undertakes an effective reform in the exercise of family affairs, the Jia family achieves its peak prosperity. Unfortunately, Xifeng contracts a serious sickness in Chapter 55,

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changing her own and the family’s destiny: she has a miscarriage soon after the New Year. Two or three doctors observe her every day but, overestimating her own strength, she still maps out plans for the household even if this aggravates her illness: Xifeng had a delicate constitution, however, and as a girl had never looked after her health. In her passion to shine she had overtaxed her strength, with the result that her miscarriage left her very weak. A month after it she was still losing blood. Although she kept this a secret, everyone could see from her pallor and loss of weight that she was not taking proper care of herself (Cao 1999, 1579).

As mentioned in Chapter 6, Lady Wang “does not handle much business any more but leaves everything to the second master’s wife” – that is, to Xifeng (175). Although Xifeng is Lady Xing’s daughter-in-law, she actually assists Lady Wang in seeing to household affairs. Her miscarriage and loss of blood mark the end of her management in the Rong Mansion. The power to order the household is transferred to Li Wan, Tanchun, and Baochai. It is at this moment that internal conflicts in the Jia family break out and an atmosphere of decline prevails in the novel. For instance, servants gather together to gamble, chefs fight for power and profit to organise the kitchen, and Concubine Zhao and actresses openly scuffle. Lady Wang’s rose-flavoured juice and Yingchun’s hairpin are stolen. Although Tanchun makes a great effort to reform the management and overcome the major drawbacks in the household, it is difficult to prevent the Jia family from beginning its decline. It is significant that Xifeng’s sickness worsens as the Jia family is gradually driven into an impasse. In Chapter 71, Xifeng and her motherin-law Lady Xing fight. When Lady Xing makes Xifeng lose face in public, Xifeng cries and has a relapse into illness: “Since her period last month she’s been having fluxions off and on non-stop” (Cao 1999, 2165). Soon afterwards, a sachet with erotic embroidery is found in the Grand Garden. Lady Xing sends it to Lady Wang, thus challenging Lady Wang’s power to manage the household. At last, the ransacking of the Grand Garden signals the intensification of the struggle between Lady Xing and Lady Wang. They represent the first and second sons of the Rong Mansion respectively and embody the aggravation of internecine conflicts: thus, the tragic decline of the Jia family is fated. It is worth noting that after Xifeng loses a good deal of blood on the night of raiding each other’s houses in the Grand Garden, she is too weak even to get up the next day. The sharp contrast between the narratives in Chapter 13 and after Chapter 55 shows that Xifeng’s state of health is an index of the rise and fall of the family.

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When Xifeng manages the Rong and Ning Mansions as a healthy and vigorous daughter-in-law, the household runs in order and goes through a prosperous period. When she has to transfer the power of managing the household to others as a patient, the crisis of “all like game-cocks fighting to finish each other off” (2261) arises in the family. The Jia Mansion is fast falling into decay, like a dying patient.

The Rewriting of Family Relationships In fictional representations of family relationships, maintaining stable family relationships is all-important. Based on blood ties and the patriarchal system, the structure, network and cultural concepts of a clan remain highly stable and are transmitted to the next generation in traditional Chinese family ethics. Thus, family ties and moral principles are deeply significant. However, as noted earlier, the fact that a person becomes a patient implies that he or she deviates from normal social relations. When a family member falls ill, he or she is exiled to the margin of the network of family relations. The disorder of his or her body and the change of the patient’s sense of space often result in the rewriting of the patient’s family relationships. Since parent-child ties and in-law ties are crucial relationships in the traditional Chinese patriarchal system, they are also the focus of many fictional medical narratives. Filial piety is not only a moral principle specifying the child’s responsibility for their parents, but is also presented as the foundation of all human relationships in imperial Chinese society and as the basis of political ethics and the education system. Thus a great many fictional medical narratives which tell of the rewriting of family relationships pay special attention to filial piety, whether as practised or as violated. It is a filial son’s duty to take care of sick parents: likewise, abandoning sick parents indicates damage to family ethics and the decline of morality. In fictional medical narratives, descriptions of unfilial conduct are usually accompanied by retribution. For example, in the sixth story of Badongtian ඵὝኳ, Shi Jiazhen suffers from a mental illness. Transformed from a decent scholar into a wandering lunatic, Shi’s daily life is completely destroyed. Clad in ragged clothes, he fights for the porridge that the local government provides for drought relief, elbowing his way into the crowd and exclaiming, “let me have the porridge” (Biliange 1985, 107). At the time, Shi is not able to understand the consequences of his behaviour and loses his inherent dignity. It is mental illness that leads to Shi’s loss of his ability to communicate with other people. This loss rewrites his family relationships: his adoptive son Yan Ao detests his illness and tries to keep

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his distance from him. Although the adopted son would normally be expected to assume the duty of supporting his foster parents, Shi and Yan’s adoptive relationship is broken because of Shi’s illness. Moreover, after Shi dies, Yan Ao does not take care of the funeral rites or offers a sacrifice, signifying that family ethics mean nothing to him. The author of the story comments, “You see how Yan Ao abandoned the ancestors. It makes no sense that he should have a good son. He will absolutely have an unworthy son to display retribution” (108). Sure enough, Yan Ao’s prodigal son Qilang is addicted to gambling and squanders Yan Ao’s whole fortune. After Yan dies of illness in a temple, Qilang goes to steal his coffin to sell. Just as Shi Jiazhen’s death opened the way to Yan Ao’s unfilial conduct, Yan Ao’s own death due to illness destroys his parentchild relationship with Qilang. Both failures of family ethics show how sickness rewrites the parent-child relationship and demonstrate the consequences of violations of filial piety. Filial piety not only refers to a family member’s morality, but also involves the legacy of a clan. The process of sickness makes real the retribution for violations of filial piety, displaying how a failed father sets examples for his son in practice. In this sense, the experience of sickness at home does not belong only to the patient himself, but also functions within a particular cultural situation and social network. Relationships with in-laws are more complicated, for parents-in-law and children-in-law are connected by marital relations rather than blood ties. The relationship between mother-in-law and daughter-in-law is perhaps the most fraught in-law relationship in a family: a great amount of late imperial vernacular fiction describes the fatal incompatibilities that can arise between mother-in-law and daughter-in-law. In these tales, a mother-in-law’s sickness is an important context in which her relationship with the daughter-in-law is rewritten. In late imperial fictional medical narratives, a mother-in-law is always in the dominant position, because her daughter-in-law is required to submit to her absolutely. Nevertheless, when she is sick, the balance of power can be transformed dramatically. For example, the thirteenth story in Pai’an jingqi᣽Ṹ傊ཷ tells the story of the family Zhao. Madam Zhao’s relationship with her daughter-in-law, Miss Yin, is not bad at the beginning. However, when Madam Zhao falls seriously ill, the family relationship is completely rewritten. Her vision blurring with rage, she felt faint and was unable to drink and eat. Her daughter-in-law did not go to her bed to look in on her, nor did she nurse her body with soup, only giving her a few bowls of yellow rice for her three daily meals. After half a month, her sickness worsened and she

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When Madam Zhao is sick in bed, relying on the care of others, she has to look up to the caregiver, while the caregiver looks down at her. The posture of their bodies symbolises an unequal relationship. According to Toombs, “to be able to ‘stand on one’s own two feet’ is of more than figurative significance. Verticality is directly related to autonomy” (Toombs 1992, 65). In this familiar home-centred space, the powerful person, Madam Zhao, suddenly occupies a different position; immobilised, looking up at a former subordinate newly empowered. Madam Zhao’s sickness and Miss Yin’s indifferent attitude towards the patient upend the in-law relationship, directly leading to the patient’s death. The total overthrow of family ethics causes a series of tragedies. Madam Zhao’s husband Zhao Liulao spends almost all of his assets on Madam Zhao’s burial and is reduced to sneaking into his son’s bedroom at night to find something to sell. His son mistakes him for a thief and kills him. In the end, the son is put to death. This story was adapted from a classical tale. The latter does not include the first half of the story, about Madam Zhao’s illness and death; instead, it just shows the father sneaking into the son’s bedroom to find some property and being killed by his son. The vernacular tale describes the cause of this family tragedy by creating a context in which the relationship between mother-in-law and daughter-in-law has been rewritten through the process of sickness. It associates the deterioration of an in-law relationship with a broken parent-child relationship. As sickness destroys the patient’s body and her relationship with her daughter-in-law, the parent-child bond is also severed. The wall between the father’s and the son’s bedrooms separates the family space and symbolises a clear emotional and economic boundary between the two generations. When Zhao Liulao digs a hole in the wall and steals into his son’s bedroom, the implication is that he is invading a space that does not belong to him. This abnormal invasion is caused by a financial crisis, which is brought about by Madam Zhao’s sickness and death. Therefore, Madam Zhao’s sickness plays a key role in this family tragedy, indicating how the disorder of the organism can propagate as disorder in family relationships and ethics. The third story in Xingshiyanරц䀰 is another example in which a mother-in-law’s illness leads to conflicts with her daughter-in-law. However, a difference in the son’s choice shows another possible direction for this kind of story. In this story, after the relationship between Zhangzhu and her mother-in-law Shengshi deteriorates because of Shengshi’s sickness, Zhangzhu secretly sells her mother-in-law to an old

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wifeless man while her husband Zhou Yulun is away on business. In the end, Zhou discovers the truth and sells his wife to that man and brings his mother back home. Zhou’s choice is widely praised in his hometown. He marries another beautiful wife and becomes an official. In the two stories above, the illness of a mother-in-law causes a broken relationship with a daughter-in-law. But the outcomes are different because of the sons’ choices. Madam Zhao’s son follows his wife’s lead and cuts off the bonds between two generations, leading to a family tragedy; Zhou Yulun sells his wife to get his mother back and wins a good reputation. It seems that the different directions of the two stories reveal the authors’ value judgement: when the relationship between a mother-inlaw and a daughter-in-law is broken, the son is regarded as dutiful only if he acts as Zhou Yulun does. This choice shows his filial piety and upholds Confucian moral principles. However, at the end of the story of Zhou, Zhangzhu is subjected to all kinds of suffering and dies after one year. Then Zhou Yulun refuses the proposal that the local magistrate commends him as a model of “a filial son,” offering the excuse that “I am not a righteous husband.” His actions indicate that in the privacy of his own conscience he feels guilty about Zhangzhu’s death, but he cannot tell anyone because of traditional Confucian values. There is a kind of crack in the text’s representation of values: on the one hand, the story speaks highly of his actions as a model of filial piety, but on the other hand, the text also expresses doubt and self-examination about his non-righteousness to his wife. Regrettably, this kind of doubt and self-examination remains in the shadow of widespread praise of Zhou’s filial piety and is not given enough space to be fully expressed. The seventh story in the Qing Dynasty collection Xingshi Qiyan䟂ц ཷ䀰 continues the consideration of how a filial son should perform when his mother and wife’s in-law relationship is troubled. The doubt and rethinking of a conventional filial son’s actions are developed in depth. In this story, Huangshi is an aggressive and termagant woman. She is rough in her treatment of her first daughter-in-law, Shun’er, whose disposition is gentle and obedient. When Shun’er’s husband Chengda is sick, Huangshi picks on her harshly. One day, when Chengda caught a cold and had a fever, Huangshi found that Shun’er was wearing make-up as she came to pay respects to her. She said Shun’er was always heavily made up to seduce her husband and that was why her husband was sick. Even now she was still looking seductive and fascinating. Was she trying to hasten her husband’s death and marry another man? Huangshi did not stop reviling her… On the second day, Shun’er wore ordinary clothes. Huangshi saw her and became even more

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It is clear that Huangshi is torturing her daughter-in-law intentionally on the pretext of her son Chengda’s sickness. Chengda has no definite views of his own and is always servile to his mother: because Huangshi is dissatisfied with Shun’er, Chengda separates from his wife and eventually divorces her. After Huangshi’s second son Cheng’er gets married, his wife Ligu is disobedient to Huangshi and even bullies her. Ligu commands Huangshi to do all the housework. If Huangshi gets up late, Ligu does not offer meals to her. Weak from physical and psychological suffering, Huangshi falls ill. She is confined to bed because of sickness, indicating that her body’s gestural display is completely changed by her sickness. Because of the loss of the upright posture, Huangshi’s independency and autonomy are severely affected. She is not able to get up by herself and has to rely on her caregivers. She has to defecate and urinate in bed and experiences the helplessness and humiliation of one who cannot control her own body. In the relationship between Huangshi and Shun’er, the former holds her head high, while the latter bows her head and submits; in the relationship between Huangshi and Ligu, the former is laid up with illness, while the latter is unbearably arrogant. Their body postures symbolise their position and power in family relationships. Huangshi’s sickness causes the transformation of her family status and offers a chance to rewrite her relationship with Shun’er. Although Shun’er has been abandoned by her husband, she secretly cooks for Huangshi after hearing about Huangshi’s condition. When Huangshi was healthy, no matter how carefully Shun’er attended on her, she was still abhorrent to Shun’er. However, when her daily life and dignity are completely destroyed by sickness, because Shun’er attempts to save her, she begins to feel guilty and brings Shun’er back home. Therefore, Huangshi’s sickness is a metaphor of salvation as well: it helps Huangshi recognise her own failing, repair her relationship with Shun’er, and finally bring an end to Ligu’s maltreatment. In the description of the family relationships between Huangshi and her two daughters-in-law, this story seems to extend the doubt and examination that are not fully developed in Zhou Yulun’s story. When Shun’er submits to Huangshi, Huangshi becomes more and more arrogant and tyrannical. Her son Chengda always obeys her and treats his wife badly; thus, Huangshi is able to convince Chengda to divorce Shun’er. In

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other words, a harsh mother-in-law’s violence reaches an extreme with the support of a filial son. In other words, she uses her son’s virtues to bind him and make him into an extension of her power. Her sickness is a political opportunity within the family. In contrast, when Huangshi meets an overbearing daughter-in-law, her attitude becomes mild because she is afraid of Ligu’s fierce temper. That is, Ligu’s impertinence trumps Huangshi’s arrogance. When Ligu maltreats Huangshi, two filial sons, Chengda and Cheng’er, both fail to stop the scheming daughter-in-law. Chengda always follows the principles of filial piety, but this produces a tragedy: he abandons a filial daughter-in-law and puts his mother in a hard situation. That Chengda is a filial son is not in question, but he encounters an ethical dilemma when dealing with the two modes of relationships between mother-in-law and daughter-in-law. In view of this, in Zhou Yulun’s story, the filial son gains a good reputation just because his mother is not as harsh as Huangshi. In this sense, Huangshi’s story reaches a considerable depth when discussing a filial son’s responsibility to deal with his mother and his wife’s relationship. In conclusion, Ming-Qing vernacular fiction paid special attention to the ordinary lives of common people. As family is the single most important space in which people spend their daily lives, a great number of fictional medical narratives centred on sickness at home. In these works, the patient often experiences the transformation of family power and family relationships. As Confucian ritual principles focus on family members’ roles and especially on a wife’s morality in discussions of an idealised family system and relations, the dimension of the body is typically absent in this large ethical framework, while morality receives the most attention. By contrast, fictional representations of patients’ experience of illness at home reassert the importance of the body. In some cases, a female member’s bodily condition not only plays a key role in her own marriage, but also reaches beyond domestic affairs and affects the outside world, which is controlled by male family members. Therefore, the body may be mute and unrecognised in certain normative views, but it finds a way in vernacular stories to make itself heard through the experience of illness, revealing flaws in the ideally integrated Confucian family/social structure. Since every person has his or her proper role and responsibilities in the family, the disorder of the patient’s body often influences the whole family system and results in the disorder of family ethics and relationships. From the perspective of traditional Chinese medicine, the human body is a whole organism situated within a larger framework of natural forces and

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society. Fictional medical narratives centred on the theme of “sickness at home” did not focus solely on how the individual person’s life was destroyed by sickness, but also paid attention to how the family system and ethics became disordered. As an altered condition of the body, sickness not only causes physical suffering but also destroys and remakes the patient’s identity and interpersonal relations, revealing how the unhealthy state of a body can bring about disorder in the whole family system and in social ethics. In this sense, the effort to heal a patient’s body always symbolises an attempt to restore order in a family or society.

References Biliange. 1985. Badongtian‫ޛ‬⍎ཙ. Beijing: Shumu wenxian chubanshe. Burnham, John. 2005. What Is Medical History? Cambridge UK: Polity Press. Cao, Xuqin. 1999. A Dream of Red Mansions, translated by Yang Xianyi and Dai Naidie. Beijing: Foreign Languages Press. Chen, Dakang. 2000. Mingdai xiaoshuo shi᰾ԓሿ䃚ਢ. Shanghai: Shanghai wenyi chubanshe. Chen, Peng. 1990. Zhongguo hunyin shigaoѝ഻ႊါਢは. Beijing: Zhonghua shuju. Chen, Yan. 1983. Sanyin jiyi bingzheng fanglunйഐᾥа⯵䅹ᯩ䄆. Beijing: Renmin weisheng chubanshe. Dong, Kai. 1983. Zhouyi zhuanyi fuluઘ᱃ۣ㗙䱴䤴. Wenyuange sikuquanshuben᮷␥䯓ഋᓛ‫ޘ‬ᴨᵜ. Taiwan: Shangwu yinshuguan. Feng, Menglong. 2009. Stories to Awaken the World, translated by Shuhui Yang and Yunqin Yang. Seattle and London: University of Washington Press. Li, Yu. 2006. Wushengxi❑㚢ᡢ. Beijing: Renmin wenxue chubanshe. Ling, Mengchu. 1996. ErpaiҼ᣽. Hubei: Hubei renmin chubanshe. Shoupuweng. 1992. Xingshiqiyan䟂цཷ䀰. Beijing: Beijing yanshan chubanshe. Toombs, S. Kay. 1992. The Meaning of Illness: A Phenomenological Account of the Different Perspectives of Physician and Patient. Dordrecht: Kluwer Academic Publishers. Wang, Pinzhen. 1983. Dadai liji jieguབྷᡤ⿞䁈䀓䁱. Beijing: Zhonghua shuju. Yang, Tianyu. 1997. Liji yizhu⿞䁈䆟䁫. Shanghai: Shanghai guji chubanshe.

CONTRIBUTORS

Cynthia J. Avila is a graduate from the University of Chicago with a degree in History, Philosophy, and Social Studies of Science and Medicine. She is a recent recipient of the Abraham Lincoln Civic Engagement Laureate Award and is the youngest recipient of the 2017 Advocate Illinois Masonic Hispanocare Award. Ms. Avila is currently enrolled in the Health Careers Program at Harvard University. Emma Domínguez-Rué graduated in English at the University of Lleida (Catalonia) and studied an MA in English Literature at Swansea University (UK). Her PhD dissertation was read in 2005 and published in 2011 with the title Of Lovely Tyrants and Invisible Women: Invalidism as Metaphor in the Fiction of Ellen Glasgow (Berlin: Logos Verlag). Aside from American Studies, she has also worked on ageing studies, narratives of disease, contemporary detective fiction, and Victorian and Gothic fiction under a feminist perspective. She is currently Associate Professor and Serra-Hunter Fellow in the Department of English and Degree Coordinator for English Studies at the University of Lleida. Anna Dudkowski-Sadowska, MA is a Teaching Assistant and PhD Candidate; she is a member of the Department of Sociology of Health, Medicine and Family, Institute of Sociology, Faculty of Philosophy and Sociology at Maria Curie-Skáodowska University (Poland) and the Independent Medical Sociology Unit, Faculty of Health Sciences at the Medical University of Lublin (Poland). She is also Section Editor (Psychology and Sociology of Health) of “General Medicine and Health Sciences” (“Medycyna Ogólna i Nauki o Zdrowiu”, MONZ). Emanuela Ettorre is Associate Professor of English Language and Translation at the University "G. d'Annunzio" of Chieti-Pescara (Italy). She has published extensively on George Gissing, Thomas Hardy, Anthony Trollope, Mary Kingsley, Charles Darwin, on animal studies, women travel writing, and the relationship between science and literature. She has published a book on the novels of Thomas Hardy, and has translated into Italian three volumes of short stories by George Gissing, Thomas Hardy and Hubert Crackanthorpe. Konrad Gunesch is Associate Professor of International Education and Linguistics in the College of Media and Mass Communication at the American University in the Emirates in Dubai. He has authored the book

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Multilingualism and Cosmopolitanism, edited the book Crossing Borders in Gender and Culture, and published over fifty peer-reviewed journal articles, book chapters and encyclopedia entries in the fields of International Education, Cultural Studies, Applied Linguistics, Media Studies, Global Tourism, Gender Studies, Sustainable Development, Ecological Economics and Comparative Literature. Krzysztof Jagusiak (born 1985) works in the Ceraneum Centre at the University of àódĨ, Poland. His doctoral thesis (2015), was devoted to cereals and vegetables in ancient and early Byzantine Greek medical treatises written between the 2nd and 7th c. AD, was read in the Department of Byzantine History at the University of àódĨ. He is co-author of three books and numerous articles about the history of ancient medicine and culinary art. Maciej Kokoszko (born 1962) is a historian and classical philologist. Since 1987 he has been working at the University of àódĨ, Poland, currently as a professor. His research interest focuses on food and the history of medicine of antiquity and the early Byzantine period. He seeks connections between alimentary patterns and medical practice (mainly in the field of dietetics and pharmacology), using medical sources written between the 1st and 7th centuries AD, with special stress on the writings of Galen. Tereza Kopecka has been a Medical Doctor since 2008 (Charles University, First Medical Faculty), a Clinical Microbiology resident since 2009 and a PhD Student in the History of Medicine since 2017 (Charles University, First Medical Faculty; supervisor prof. Petr Svobodny). She focusses on the prosopography of medical students and physicians of the 20th century, the history of various medical specialties and the social history of Czechoslovakia. Arto Mutanen received his PhD degree at the University of Helsinki. He is Adjunct Professor at the Finnish National Defence University and Researcher at the Finnish Naval Academy. His research area includes philosophy, philosophy of science, philosophy of education, and philosophy of action. He has published several international papers in the field. Professor Wáodzimierz Piątkowski is a graduate of Warsaw University, where he specialised in the sociology of medicine under the supervision of Professor Magdalena Sokoáowska, co-founder of European Sociology of Health, Illness and Medicine. He is currently working as Head of the Department of Sociology of Health, Medicine and Family, at Maria Curie-Skáodowska University, Lublin, Poland and at the Faculty of Health Sciences, Medical University of Lublin. Professor Piątkowski is the

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Founder of the Department of Medical Sociology (1995) at Lublin's Medical University. In 2001-2013 he was Chairman of the Medical Sociology Section, Polish Sociological Association (PTS). In 1990, he was elected National Coordinator of the European Society for Health and Medical Sociology (ESHMS). Maria Skomorowska is a PhD candidate at Wroclaw University of Science and Technology in the Faculty of Architecture. Her doctoral research focuses on Silesian spa towns. She received her MSc in Architecture from the Wroclaw University of Science and Technology and her MA in Art History from the University of Wrocáaw. Her research interests centre around modern architectural history. Daria Sáonina is a PhD student at the Wrocáaw University of Science and Technology in the Faculty of Architecture. Her research interests focus on the connection between landscape architecture and health, including healing gardens. As a landscape architect, she is interested in shaping space in the city, which is why she participates in many contests that spread the idea of sustainable development. Her latest achievement was winning the competition for the design of a therapeutic garden at the school. Currently, she focuses on studies on the development of the garden at healing facilities in the US and Europe. Dr. Adrian Tait is an independent scholar and environmental critic. A long-standing member of the Association for the Study of Literature and the Environment (ASLE-UKI), he has regularly published in its journal, Green Letters. He has also contributed to a number of other scholarly journals, including European Journal of English Studies (2018), and to essay collections such as Thomas Hardy, Poet: New Perspectives (2015), Nineteenth-century Transatlantic Literary Ecologies (2017), Victorian Ecocriticism (2017), and Enchanted, Stereotyped, Civilized: Garden Narratives in Literature, Art and Film (2018). He continues to explore the way in which nineteenth-century and early modern depictions of the environment anticipate but also challenge contemporary, ecocritical concerns. Stephen Wallace (PhD, MSc, Dip Ed Psych, Dip Ed, BA) retired from full-time academic work in 2013 as an Associate Professor. Over a working life of four decades, he worked (mainly in Australia) as an academic, researcher, teacher, counsellor and policy advocate serving in government, education, and community work. In later years his developed expertise in clinical sciences led to posts in clinical governance in the NHS and post-graduate medical education in the UK. He has a modest publication record across a range of areas from ethics to epidemiology,

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and continues to present and publish his research internationally from time to time. Ying Wang is a Ph.D. candidate in Department of Asian Languages and Cultures at University of California, Los Angeles. She received her BA in Sinology from Wuhan University and her MA in Chinese Language and Literature from Peking University in China. She specializes in fiction, drama, and material culture in late imperial China. Currently she is working on her dissertation, “Constructing Patients: Medical Narratives in Late Imperial Chinese Vernacular Fiction.” Other areas of her interest are: representation of gender and body, performing arts of kunqu opera, and medical humanities.